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Digitized  by  the  Internet  Archive 

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Open  Knowledge  Commons 


http://www.archive.org/details/practiceofmedicOObyfo 


THE  PRACTICE 


MEDICINE  AND  SURGERY/ 


APPLIED  TO  THE 


DISEASES  AND  ACCIDENTS  INCIDENT  TO  WOMEN. 


By  W.  H.  BYFORD,  A.M.,  M.D., 

PROFESSOR  OF  GYNECOLOGY  IN  RUSH  MEDICAL  COLLEGE,  AND  OP  OBSTETRICS  IN  THE  WOMAN'S 
MEDICAL  COLLEGE  ;  SURGEON  TO  THE  WOMAN'S  HOSPITAL  OF  CHICAGO  ;  EX- 
PRESIDENT  OF  THE  AMERICAN  GYNECOLOGICAL    SOCIETY  ; 
EX-VICE-PRESIDENT  OF  THE  AMERICAN 
MEDICAL  ASSOCIATION,  ETC. 

AND 


HENRY  T.  BYFORD,  M.D., 


SURGEON  TO  THE  WOMAN'S  HOSPITAL  OP  CHICAGO ;  GYNECOLOGIST  TO  ST.  LUKE'S  HOSPITAL  ; 

PRESIDENT  OF  THE  CHICAGO  GYNECOLOGICAL  SOCIETY  ;  MEMBER  OF  AMERICAN 

MEDICAL  ASSOCIATION  ;  OP  ILLINOIS  STATE  MEDICAL  SOCIETY  ; 

OF  CHICAGO  MEDICAL  SOCIETY,   ETC. 


FOUKTH  EDITION. 

REVISED,  REWRITTEN  AND  VERY  MUCH  ENLARGED 

WITH 

THREE   HUNDRED   AND   SIX   ILLUSTRATIONS. 


PHILADELPHIA: 

P.    BLAKISTON,    SON    &   CO., 

No.   1012  Walnut  Street. 

1888. 


/o/ 


COPYEIGHT,  18S7, 
BY 

P.  BLAKISTON,  SOX  &  CO. 


X 

^^^  PREFACE  TO  THE  FOORTH  EDITION, 


In  no  other  branch  of  medicine  or  surgery  has  there  been  more 
rapid  and  greater  advances  made  during  the  past  few  years  than  in 
gynaecology.  This  has  necessitated  a  complete  revision  of  my  book, 
entailing  the  rewriting  of  many  sections,  the  addition  of  much  new 
material,  and  the  consequent  enlargement  of  the  volume. 

The  principal  additions  are  the  chapters  on  "  Practical  Observations 
upon  the  Anatomy  and  Physiology  of  the  Female  Pelvic  Organs ;  " 
"  Examination  of  the  Female  Pelvic  Organs  "  ( three  chapters ) ; 
''  Displacements  of  the  Uterus  "  (three  chapters)  ;  "  Affections  of  the 
Ovaries  "  and  "  Fallopian  Tubes ;  "  and  the  paragraphs  upon  "Oojoho 
rectomy,"  "  Tumor  of  the  Broad  Ligament,"  etc. 

While  Chapter  I  is  intended  to  supplement  the  general  knowledge 
of  anatomy  and  physiology  obtained  at  the  medical  colleges,  Chapters 
II  and  III  are  intended  as  a  study  of  the  anatomy  and  relation  of 
the  pelvic  structures  as  they  are  encountered  clinically.  The  value  of 
a  proper  understanding  of  the  anatomy,  physiology  and  topography 
of  these  special  organs  cannot  be  overestimated,  and  it  is  hoj)ed  that 
this  section  will  be  found  of  service  both  to  practitioner  and  student. 
The  chapter  on  "  Lacerations  of  the  Perineum  and  Pelvic  Floor  "  has 
been  rewritten,  with  the  end  in  view  of  enabling  the  young  practitioner 
to  treat  these  accidents  with  discriminating  intelligence,  instead,  as  is 
so  often  the  case,  of  learning  to  carve  all  injured  perinsea  to  suit  one 
stereotyped  operation.  Chapters  XXIX,  XXX,  and  XXXI,  on 
"  Displacements  of  the  Uterus "  have  been  rewritten  and  Chapter 
XXXII  revised  with  a  similar  intention.  The  chapters  on  the  "Affec- 
tions of  the  Ovaries  "  and  "  Fallopian  Tubes  "  have  also  been  revised, 
and  the  subject  of  oophorectomy  rewritten. 

New  matter  concerning  tumor  of  the  broad  ligament  and  pelvic 
abscess  (see  chronic  perimetritis)  has  been  added,  and  some  additions 
to  Chapters  III,  XII,  XXV,  XXXV,  XXXVI,  XXXIX,  XLVIII,  and 
others,  made. 


IV  PEEFACE. 

Some  subjects,  such,  for  instance,  as  cancer  of  the  uterus,  might 
have  been  more  extensively  revised,  but  it  has  been  thought  better,  in 
view  of  the  indefinite  state  of  our  knowledge  upon  them,  to  limit  the 
alterations  to  correspond  to  that  which  is  most  settled  and  useful  from 
a  23ractical  standj)oint. 

The  illustrations,  over  one  hundred  and  fifty  of  which  are  new,  have 
been  carefully  selected,  a  majority  of  them  (excepting  cuts  of  instru- 
ments) being  from  original  drawings  made  especialh^  for  this  edition. 

A  large  part  of  the  work  of  revision  and  editing  having  been  done 
by  Henry  T.  Byford,  M.D.,  I  feel  that  an  ordinary  acknowledgment 
of  his  ser\dces  would  be  inadequate;  I,  therefore,  believe  it  only  just 
to  place  his  name  on  the  title-page  as  one  of  the  authors.  Acknowl- 
edgment is  also  due  to  Dr.  Robert  J.  Hess,  of  Philadelphia,  for  his 
services  in  reading  proof  and  preparing  the  indexes. 

AVe  have  endeavored  throughout  the  book  to  give  the  proper  credit 

to  all  workers  in  this  field  whenever  referred  to,  but  I  wish  here  to 

render  my  general  acknowledgment  to  all. 

W.  H.  B. 
Chicago,  December,  1887. 


CONTENTS. 


CHAPTER   I. 

PRACTICAL  OBSERVATIONS  UPON  THE  ANATOMY  AND  PHYSIOLOGY  OF 
THE  FEMALE  PELVIC  ORGANS. 

I.  PELVIC    ROOF,  18.      Musculature   of  the  pelvic  roof,  19.      Peritoneal 

covering  of  the  pelvic  roof,  22.  Pelvic  connective  tissue,  23.  The 
ovaries  and  their  relations,  2.5.  Ureters,  27.  Vagina,  28.  Plane  of  the 
pelvic  roof,  31.  Relation  of  uterus  to  bladder,  31.  Relation  of  pelvic 
roof  to  pelvic  floor,  32. 

II.  THE    PELVIC    FLOOR,   32.     Relation  of  the  muscles  of  the  pelvic 

floor  and  interposed  tissues,  34.  Abdominal  pressure,  35.  Requirements 
for  the  closure  of  the  pelvic  floor  insufficiency,  38. 

III.  PERINEUM,    39.     Perineal  body,   42.     Measurements   of  the  perineal 

body,  42.  Characteristics  of  the  perineal  body,  43.  Action  of  the 
perineum  as  a  support,  44.  The  rectum,  46.  The  bladder,  50.  The 
bloodvessels,  51.     Nerves  53.     Lymphatics,  53. 

CHAPTER   IT. 

EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS. 

Position  of  patient  for  examination,  56.  Percussion  of  the  pelvic  organs,  58. 
Palpation  of  pelvic  roof — digital  examination  through  the  vagina,  58. 
Characteristics  of  the  cervix  uteri,  59.  The  virgin  cervix,  59.  The  cervix 
uteri  of  the  child-bearing  woman,  59.  The  senile  cervix,  60.  Location  of 
the  cervix  uteri,  61.  Corpus  uteri,  63.  Palpation  of  the  displaced 
uterus,  63.  Palpation  of  the  pregnant  uterus,  64.  Examination  of 
the  uterus  during  general  anaesthesia,  65.  Digital  exploration  of  the 
pelvic  roof  through  the  vagina,  67.  The  advantages  of  a  gentle 
touch,  67.  When  not  to  examine,  68.  Precautions  necessari^  during 
examination,  68.  Difiiculty  of  difi"erentiating  pelvic  tissues  by  the  touch,  68. 
The  starting  point  in  digital  explorations  of  the  pelvic  roof,  69.  How  to 
palpate  the  ovaries,  69.  Table  of  position  of  ovaries,  72.  Palpation  of  the 
ovarian  ligament,  72.  The  infundibulo-pelvic  hgament,  73.  Palpation  of 
the  round  ligament,  74.  '  Palpation  of  the  Fallopian  tubes,  77.  Palpation 
of  the  ureters,  78.  How  to  find  the  ureters  with  cervix  in  normal  j^osition, 
79.  Palpation  of  the  ureters  when  the  cervix  is  displaced  backward,  80. 
Palpation  of  the  ureters  when  the  cervix  is  displaced  forwards,  80.  Difter- 
entiation,  81,     Palpation  of  the  broad  ligaments,  81.     Vaginal  palpation  of 


VI  CONTEXTS. 

the  sacro-uterine  ligaments,  83.  Palpation  of  the  pubo-vesico-uterine 
ligament,  86.  Palpation  of  the  vagina,  88.  Rectal  examination  of  the 
pelvic  roof,  90.  Method  of  rectal  indagation,  91.  Digital  exploration 
through  the  upper  rectum,  93.  The  recto-vaginal  grip,  95.  Circumdigita- 
tion  of  the  uterus  from  the  abdomen,  vagina  and  rectum,  95.  Palpation  of 
the  interior  of  the  bladder,  96. 

CHAPTEE   III. 

EXAMINATION  OF  THE  FEMALE  PELVIC  OEGANS — CONTINUED. 

The  pelvic  floor  and  perineum,  98.  Vaginal  jDalpation  of  the  pelvic  floor,  98. 
The  small  sacro-sciatic  ligament,  and  ischial  spine,  99.  The  pyriformis,  99. 
The  great  sacro-sciatic  foramen  and  sacral  promontory',  100.  The  coccygeus, 
101.  The  levator  ani,  101.  Control  of  the  pelvic  floor  muscles  by  will,  102. 
The  obturator  internus,  103.  Rectal  examination  of  the  pelvic  floor,  104. 
Palpation  of  the  arteries  of  the  pelvis,  104.  Vaginal  palpation  of  arteries, 
105.  Rectal  palpation  of  the  pelvic  arteries,  107.  Palpation  of  pelvic 
nerves,  107.  Examination  of  the  perineum,  108.  Examination  of  the 
vaginal  orifice,  108.  The  levator  vaginae  and  levator  ani,  108.  Examination 
of  the  vulval  orifice,  110.  The  constrictor  cunni  or  vulval  sphincter.  111. 
The  pubic  fossa,  111.  Transversus  perinjei,  112.  Characteristics  of  the 
perineal  body,  112.  Rectal  palpation  of  the  perineal  body,  113.  Digital 
aversion  of  the  vagina,  113. 

CHAPTER   lY. 

INSTRUMENTAL  EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS. 

Object  in  using  the  sound  or  probe,  114.  Size  and  length  of  sound,  114.  Mode 
of  using,  117.  Length  of  the  cervical  and  uterine  cavities,  117.  Speculum, 
120.  Position  of  patient  for  speculum,  121.  Mode  of  using  the  speculum, 
122.  How  to  find  the  os  uteri,  123.  Appearance  of  the  os  and  cervix  in 
the  virgin,  125.  Appearance  of  the  multiparous  uterus,  126.  Appearance 
in  the  aged,  126.  Exceptions  to  these  appearances,  127.  Color,  127. 
Appearance  of  secretion,  127.  Indication  of  mucus  in  abundance,  127. 
Indication  from  pus,  128.  Probe  and  speculum  conjointly,  128.  Dilata- 
tion, 128.  Exploratory  curetting  of  the  uterus,  133.  The  use  of  the 
female  catheter,  134.  The  urethral  speculum  and  endoscope,  135.  Cath- 
eterization of  the  ureters,  136.  General  manner  of  conducting  an  examina- 
tion in  making  a  diagnosis,  138. 

CHAPTER  V. 

DISEASES  AND  ACCIDENTS  OF  THE  LABIA  AND  PERINEUM. 

Wounds,  142.     Sanguineous  infiltration,  143.  Varices  of  the  labia  and  vulva, 

143.      Qlldema,    144.      Phlegmon,    144.  Abscesses    of   the    labia,    146. 

Labial  hydrocele,  146.  Labial  tumors,  147.  Hypertrophied  labia,  147. 
Cancer  of  the  labia,  149. 


CONTENTS.  Vll 

CHAPTER  YI. 

DISEASES  OF  THE  VULVA. 

Condylomata  of  the  vulva,  150.  Treatment,  150.  Inflammations,  150.  Treat- 
ment, 151.  Follicular  vulvitis,  152.  Causes,  152.  Treatment,  152. 
Pruritus  pudendi,  153.  Treatment,  154.  Corroding  ulcer,  155.  G-angre- 
nous  vulvitis,  or  noma,  156.  Urethral  excrescences,  157.  Vascular  urethra, 
158.     Hypertrophy  of  the  clitoris  and  nympha,  159.     Treatment,  159. 

CHAPTEE   VII. 

LACERATION  OF  THE  PERINEUM  AND  PELVIC  FLOOR. 

Preliminary  observations  upon  the  conditions  leading  to  injuries  of  the  parturient 
canal,  160.  The  mechanism  of  laceration  and  injuries  of  the  perineum  and 
pelvic  floor,  161.  The  sciatic  and  coccygeal  surface,  161.  Plane  of  obturato- 
coccygeus,  162.  The  levator  coccygei,  163.  The  plane  of  the  levator  ani 
proper,  164.  Plane  of  the  levator  vaginse  or  vaginal  sphincter,  164.  Plane 
of  the  constrictor  cunni  or  vulval  sphincter,  167.  The  vulval  plane  or  ring, 
167.  Lacerations  extending  into  the  transversus  perin?ei  and  sphincter 
ani,  168.  Lacerations  of  the  perineal  septum,  168.  Lacerations  of  the  deep 
pelvic  fascia,  168.  The  flap  lacerations,  168.  Central  ruptures,  169. 
Irregular  lacerations,  169.  Concealed  lacerations,  170.  Contusions  about 
the  bony  walls,  171.  Lacerations  extending  into  the  rectum,  171.  Effects 
of  perineal  and  pelvic  floor  lacerations,  171.  The  immediate  eff"ects  or  those 
incident  to  the  puerperal  state,  171.  Eemote  eff'ects,  172.  Effects  upon 
the  uterus,  172.  Effects  upon  the  bladder,  urethra,  and  rectum,  173. 
Effects  upon  the  vagina,  174.  Other  effects,  174.  Symptoms  of  perineal 
and  pelvic  floor  lacerations,  174.  Secondary  symptoms,  174.  Varieties  of 
laceration,  175.  Degrees  of  laceration,  176.  Diagnosis  of  perineal  and 
pelvic  floor  lacerations,  177.  Palpations  of  old  perineal  lacerations,  180. 
Diagnosis  by  rectal  palpation,  181.  Diagnosis  by  inspection,  183.  Combined 
palpation  and  inspection,  184.  Diagnosis  of  old  lacerations  extending  into 
the  rectum,  184.  Diagnosis  of  lacerations  of  the  pelvic  floor,  184.  Deeper 
portions  of  the  pelvic  floor,  185.  Method  of  diagnosis,  186.  Prognosis, 
187.  Prevention  of  lacerations,  187.  Perineal  incisions,  188.  Colpotomy, 
189.  Episiotomy,  189.  Perineal  tenotomy,  190.  Delivery  after  perineal 
incisions,  192.  Choice  of  methods,  l92.  After  management,  193. 
Treatment  of  perineal  lacerations,  193.  Superficial  lesions,  193.  Treat- 
ment by  coaptation,  193.  Immediate  perineorrhaphy,  194.  Reasons  for 
failure  of  the  immediate  operation,  194.  Contraindications,  194.  The 
operation,  195.  Lacerations  into  the  rectum,  199.  Secondary  perineor- 
rhaphy, 199.  What  is  to  be  accomplished,  200.  When  to  operate,  200. 
Methods  of  restoring  the  perineum  when  the  rectum  is  not  opened,  200. 
The  median  triangular  operation,  200.  The  modified  triangular  operation, 
201.  The  bilateral  operation,  202.  Crescent  operation,  204.  Emmet's 
crescent  operation,  205.  Transverse  denudations,  205.  Star  operation, 
205.  Flap  operations,  206.  The  triangular  flap  operation,  206.  Bischoff's 
operation,  207.     Modified  Freund's  operation,  208.     Crescentic  flap  opera- 


Vlll  CONTENTS. 

tion,  208.  Unilateral  flap  operation,  209.  Operations  upon  uncicatrized 
lacerations,  210.  Lacerations  involving  the  sphincter  ani  but  not  the  rectum, 
210.  Closure  of  lacerations  extending  a  short  distance  into  the  rectum, 
210.  Flap  operations,  211.  Lacerations  extending  high  up  into  the  rectum, 
214.  Choice  of  methods,  215.  Preparation  of  the  patient,  216.  Prepara- 
tions for  operating,  216.  Operative  detail,  217.  Sutures,  218.  The 
quilled  suture,  219.     Incision  of  sphincter  ani,  221,     After-treatment,  221. 

CHAPTER   yill. 

DISEASES  OF  THE  BLADDER. 

Paralysis  of  the  bladder,  223.  Prognosis,  223.  Symptoms,  223.  Diagnosis, 
224.  Treatment,  224.  Hemorrhage  from  the  bladder,  22.5.  Hypersesthesia 
of  the  bladder  and  urethra  —  irritable  bladder  and  urethra,  225.  Causes, 
226.  Treatment,  226.  Chronic  inflammation  of  the  bladder,  227.  Nature 
and  progress,  227.  Symptoms,  227.  Diagnosis,  228.  Prognosis,  228. 
Treatment,  228.  Stone  in  the  bladder,  231.  Symptoms,  232.  Diagnosis, 
232.  Treatment,  233.  Foreign  bodies,  234.  Inversion  of  the  bladder, 
235. 

CHAPTER  IX. 

AFFECTIONS  OF  THE  VAGINA. 

Absence  of  the  vagina,  236.  Causes,  236.  Diagnosis,  236.  Atresia  vaginae, 
237.  Diagnosis,  237.  Prognosis,  238.  Treatment  of  atresia  and  absence 
of  tlie  vagina,  238.  Tumors  in  the  vagina,  240.  Vaginismus,  241.  Diag- 
nosis, 242.  Prognosis,  242.  Treatment,  242.  Acute  vaginitis,  243. 
Diagnosis,  244.  Prognosis,  244.  Cause,  244.  Treatment,  244.  Chronic 
vaginitis,  245.  Symptoms,  245.  Diagnosis,  246.  Causes,  246.  Prognosis, 
246.  Treatment,  247.  Puerperal  vaginitis,  248.  Sj^mptoms,  249.  Treat- 
ment, 250.  Urinary  fistula,  251.  Diagnosis,  252.  Prognosis,  253. 
Treatment,  254.  Simon's  method,  264.  Kolpokleisis,  268.  Bozeman's 
method,  271.  Entero-vesical  fistula,  274.  Entero-vaginal  fistula,  275. 
Recto-vaginal  fistula,  275.     Treatment,  275. 

CHAPTER  X. 

MENSTRUATION  AND  ITS  DISORDERS. 

Puberty,  278.  Amenorrhoea,  282.  Pathology  and  morbid  anatomy,  283. 
Symptoms,  283.  Amenorrhoea  from  retention,  286.  Diagnosis,  286.  Diag- 
nosis of  retention,  288.     Prognosis,  289.     Treatment,  290. 

CHAPTER  XI. 

MENORRHAGIA  AND  METRORRHAGIA. 

Treatment  of  menorrhagia,  300.  Palliative  treatment,  301.  Curative  treatment, 
304. 


CONTENTS.  IX 

CHAPTER  XII. 

DYSMENORRHCEA. 

Diagnosis,  309.  Prognosis,  309.  Treatment,  309.  The  inflammatorj'  form  of 
dysmenorrhoea,  310.  Symptoms,  310.  Diagnosis,  311.  Prognosis,  311. 
Treatment,  311.  Membranous  dysmenorrhoea,  312.  Symptoms,  313. 
Diagnosis,  313.  Treatment,  314.  Obstructive  dysmenorrhoea,  314.  Symp- 
toms, 316.  Diagnosis,  316.  Prognosis,  317.  Treatment,  317.  Superficial 
trachelotomy — Peaslee's  operation,  322.  (a)  Representing  stenosis  of  the 
internal  os,  322.  (b)  Representing  stenosis  of  the  external  os,  323. 
Dilatation,  326. 

CHAPTER   XIII. 

METATITHMENIA,  OR  MISPLACED  MENSTRUATION.       PERIUTERINE 

HEMATOCELE. 

Symptoms,  332.  Diagnosis,  334.  Prognosis,  335.  Treatment,  336.  Chronic 
Retrouterine  Hasmatocele,  338.     Diagnosis,  341.     Treatment,  342. 

CHAPTER   Xiy. 

CHANGE  OF  LIFE MENOPAUSE  AND  SENILITY. 

CHAPTER  Xy. 

ACUTE  INFLAMMATION  OF  THE  UN  IMPREGNATED  UTERUS. 

Causes,  346.  Symptoms,  346.  Prognosis,  347.  Diagnosis,  347.  Treatment, 
348. 

CHAPTER  XVI. 

GENERAL  CONSIDERATIONS  ON  "  UTERINE  DISEASE,"  OR 
HYSTEROPATHY. 

CHAPTER  XVII. 

SYMPATHETIC  OR  REFLEX  SYMPTOMS  OF  UTERINE  DISEASE. 

Sympathy  of  the  stomach,  353.  Sympathetic  disease  of  the  bowels,  354. 
Sympathetic  affection  of  the  liver,  354.  Sympathetic  affections  of  the  ner- 
vous system,  355.  Accompanying  manifestations  of  moral  and  intellectual 
perverseness,  356.  Syncopal  convulsions  —  hystero-epilepsy,  356.  Moral 
and  mental  derangement,  357.  Cephalalgia,  358.  Affections  of  the  spinal 
cord,  360.  Hypersesthesia,  360.  Anaesthesia,  361.  Spasms,  361.  S3'm- 
pathetic  pains  in  the  pelvic  region,  361.  Extension  of  inflammation  to  the 
bladder  and  rectum,  361.  Affections  of  the  sciatic  and  anterior  crural 
nerves,  362.  Muscular  weakness,  362.  Circulatory  system,  363.  Respi- 
ration, 364.  Sj^mpathy  of  the  excretory  organs,  365.  Mammary  bodies, 
366. 


X  CONTENTS. 

LOCAL  SYMPTOMS,  369.  Pain  in  the  sacral  or  lumbar  region,  369.  Pain 
in  the  loins,  370.  Liability  to  walk,  370.  Pain  in  the  iliac  region,  370. 
Soreness  in  the  iliac  region,  371.  Pain  in  the  side,  above  the  ilium,  37]. 
Weight,  or  bearing-down  pain,  or  uterine  tenesmus,  371.  Leucorrhoea,  371. 
Amount  of  leucorrhoea  not  always  proportioned  to  extent  of  disease,  372. 
Yellow  leucorrhoea,  when  there  is  abrasion  or  ulceration,  373.  How  is  the 
pain  produced?  373.  Bearing-down  not  always  caused  by  displacements, 
373.  Severity  of  suflPering  not  commensurate  with  amount  of  disease,  374. 
Effects  on  the  functions  of  the  uterus,  374.  Pain  during  menstruation, 
375.  Kind  of  pain  attendant  upon  uterine  inflammation,  375.  Cramping 
pain,  375.  Effects  of  partial  closure  of  the  os  uteri  on  menstruation,  375. 
Manner  of  flow  modified  by  inflammation  and  congestion,  376.  Duration  of 
the  flow,  376.  Menorrhagia,  377.  Menorrhagia  frequent  in  endocervicitis, 
377.  Amenorrhoea  sometimes  results,  377.  Function  of  generation  affected 
by  it,  378.  Sterilit3^,  378.  Abortion,  379.  Conditions  of  the  uterus  in 
abortion,  379.  Effect  upon  labor,  380.  Effects  upon  the  post-partum  con- 
dition, 380. 

CHAPTER   XVIII. 

PATHOLOGY  OR  HYSTEEOPATHY. 

Mucous  inflammation,  386.  Seat  of  mucous  inflammation,  387.  Cavitj'  of  the 
body  of  the  uterus,  387.  Endocervicitis,  387.  Endocervicitis  with  dimin- 
ished size,  388.  Endocervicitis  in  virgins,  388.  Endocervicitis  in  aged 
women,  388.  External  inflammation  combined  withinternal  in  child-bearing 
women,  388. 

CHAPTER   XIX. 

ETIOLOGY  OF  UTERINE  DISEASE. 

CHAPTER  XX. 

DIAGNOSIS  OF  UTERINE  DISEASE. 

Characteristic  signs  of  inflammation,  392.  Diagnosis  of  endocervicitis,  392. 
Diagnosis  of  submucous  inflammation,  393.  Complication  of  mucous  with 
submucous  inflammation,  393.  Size  of  the  uterus  ordinarily  increased — 
exceptions,  393.     Atrophy  as  the  result  of  inflammation,  394. 

CHAPTER   XXL 

GENERAL  TREATMENT  OF  UTERINE  DISEASE. 

Main  objects  of  general  treatment,  397.  Greneral  symptoms  requiring  special 
attention,  399.  Nervous  prostration,  399.  Food,  etc.;  401.  Nervous 
excitability,  401.  Anaemia,  403.  Plethora,  4()4.  Local  congestions,  404. 
Constipation,  405. 


CONTENTS.  XI 

CHAPTER   XXII. 

SPECIAL  TREATMENT. 

Baths,  415.  Hip-bath,  416.  Temperature  of  bath,  416.  Shower-bath,  417. 
Sponge-bath,  417.  Vaginal  injections,  irrigation,  douches,  417.  Accident 
in  injection,  419.     Should  thejf  be  used  in  pregnancy  ?  420. 

LOCAL  TREATMENT,  422.  Local  alteratives,  426.  Treatment  of  endo- 
metritis, 429. 

CHAPTER  XXIII. 

LACERATIONS  OE  THE  CERVIX  UTERI. 

Causes,  435.  The  degree,  locality  and  direction,  436.  Effects  of  the  laceration, 
436.  Effects  on  the  body  of  the  uterus,  437.  Complications,  437.  Symp- 
toms, 438.  Diagnosis,  438.  Treatment,  438.  Preparatory  treatment,  439. 
The  operation,  440. 

CHAPTER   XXIV. 

OCCASIONAL  UNTOWARD  EFFECTS    OF    UTERINE    MANIPULATIONS  AND 

OPERATIONS. 

CHAPTER   XXV. 

HYPERTROPHY  OF  THE  CERVIX. 

Diagnosis,  446.     Elongation  of  the  supravaginal  cervix,  447. 

CHAPTER   XXVI. 

ACUTE  PERIMETRITIS. 

Causes,  454.  Symptoms,  454.  Diagnosis,  457,  Prognosis,  459.  Local  peri- 
tonitis, 460.  Causes,  461.  Symptoms,  461.  Diagnosis,  463.  '  Prognosis, 
464.     Treatment  of  perimetritis,  464. 

CHAPTER  XXVII. 

CHRONIC  PERIMETRITIS. 

Causes,  469.     Varieties,  469.     Symptoms  and  diagnosis,  471.     Treatment,  473. 
CHAPTER  XXVIII. 

DISPLACEMENTS  OF  THE  VAGINA,  BLADDER  AND  RECTUM. 

Urethrocele,  cystocele,  479.  Rectocele,  479.  Symptoms,  479.  Diagnosis,  480. 
Causes,  480.     Treatment,  481. 


XU  CONTENTS. 

CHAPTER   XXIX. 

DISPLACEMENTS  OF  THE  UTERUS. 

What  constitutes  a  displacement  of  the  uterus,  486.  Causes  of  uterine  dis- 
placements, 486.  Of  descent  and  lapse,  486.  Of  prolapse  and  procidentia, 
487.  Of  displacements  forward,  backward,  sideways,  487.  Of  versions, 
487.  Of  flexions,  489.  Torsion  or  twisting,  493.  Symptoms  of  uterine 
displacement,  494.     Diagnosis  of  uterine  displacements,  495. 

CHAPTER  XXX. 

DISPLACEMENTS  OF  THE  UTERUS CONTINUED. 

Treatment  of  uterine  displacements  —  prophylactic,  498.  Treatment  of  simple 
dislocations,  upward,  forward,  and  backward,  498.  Descent  or  lapse,  500. 
Prolapse  and  procidentia,  501.  Measures  for  diminishing  the  weight  of  the 
uterus,  501.  Measures  to  strengthen  or  elevate  the  pelvic  roof  supports, 
501.  Cauterization,  504.  Partial  closure  of  the  vagina,  504.  Abdominal 
section,  505.  Measures  to  supplement  or  restore  the  pelvic  floor  and  perineal 
supports,  505.  Hysterophores  or  pessaries,  505.  Plastic  operations  upon 
the  perineum  or  pelvic  floor,  509.     Choice  of  methods,  51 1. 

TREATMENT  OF  VERSIONS,  511.*  I.  Anteversion,  511.  Vaginal  tam- 
ponment,  512.  Anteversion  pessaries,  51 2.  II.  Retroversion,  514.  In  the 
acute  and  subacute  stages,  514.  Replacement,  514.  Adhesions,  515.  The 
vaginal  pack,  516.  Breaking  up  of  adhesions,  516.  Mechanical  support, 
517.  Pessaries  acting  in  front  of  the  cervix,  or  barrier  pessaries,  518. 
Pessaries  acting  behind  the  cervix,  or  traction  pessaries,  521.  Pessaries 
acting  both  in  front  and  behind  the  cervix,  522.  Pessaries  acting  within  the 
cervical  canal,  523. 

CHAPTER  XXXI. 

DISPLACEMENTS  OF  THE  UTERUS — CONTINUED. 

Operative  procedures  for  retroversion,  525.  To  restore  the  uterus  to  its  natural 
condition,  525,  To  restore  the  function  of  the  uterine  supports,  525. 
Shortening  of  the  sacrouterine  ligaments,  525.  Shortening  the  round  liga- 
ments, or  the  Alexander- Adams  operation,  527.  Indications,  528.  Contra- 
indications, 528.  The  operation,  528.  After-treatment,  531.  Results  of 
the  operation — cases,  531.  Dangers  and  difficulties,  534.  Raising  of  the 
perineum  or  pelvic  floor,  534.  Operations  of  expedience,  535.  Abdominal 
section  for  fixing  the  fundus  forward,  535.  Operation  for  holding  or  fixing 
the  cervix  backward,  535.     Treatment  of  uterine  flexions,  536. 

CHAPTER  XXXII. 

DISPLACEMENTS  OF  THE  UTERUS — CONTINUED. 

Retroversion  and  retroflexion  of  the  uterus  during  pregnancy,  539.     Causes,  539. 
Symptoms,  540.     Diagnosis,  541.     Termination,  541.     Treatment,  541. 


CONTENTS.  Xin 

CHAPTER   XXXIII. 

DISPLACEMENTS  OF  THE  UTERUS — CONTINUED. 

Inversion  of  the  uterus,  543.  Symptoms,  544.  Diagnosis,  545.  Prognosis, 
546.     Treatment,  546.     The  treatment  of  the  chronic  form,  549. 

CHAPTER  XXXIV. 

DISEASED  DEVIATIONS  OF  INVOLUTION  OF  THE  UTERUS. 

Causes,  558.  Symptoms,  559.  Prognosis,  559.  Treatment,  559.  Subinvolu- 
tion of  the  uterus,  562.  Causes,  565.  Frequency  of  its  occurrence,  565. 
Symptoms  and  diagnosis,  566.  Diagnosis,  566.  Prognosis,  567.  Treat- 
ment, 567.  Hyperinvolution,  570.  Causes,  570.  Symptoms,  570.  Diag- 
nosis, 571. 

CHAPTER  XXXY. 

CANCER  OF  THE  UTERUS. 

Symptoms,  574.  Causes,  576.  Diagnosis,  577.  Prognosis,  578.  Treatment, 
579.     PaUiation,  575. 

CHAPTER  XXXYI. 

EPITHELIOMA,  CANCROID,  EPITHELIAL  CANCER  OF  THE  UTERUS. 
Diagnosis,  592.     Prognosis,  593.     Treatment,  594. 

CHAPTER  XXXVII. 

SARCOMA. 

Symptoms,  607.     Diagnosis,  608.     Prognosis,  609.     Treatment,  609. 

CHAPTER  XXXVIII. 

TUMORS  OF  THE  UTERUS. 

Fibrous  tumors,  610.  Their  nature,  612.  Symptoms,  614.  Diagnosis,  617. 
Prognosis,  619. 

CHAPTER  XXXIX. 

FIBROUS  TUMORS  OF  THE  UTERUS — CONTINUED. 

Treatment,  624.  Cases,  628.  Summary  of  cases  cured  by  absorption,  641. 
Modes  of  using  ergot,  642.  Different  preparations,  644.  Auxihary  treat- 
ment, 646.  Corrective  treatment,  646.  Modus  operandi,  647.  Treatment 
by  electricity,  654*.  Apostoli's  method,  655.  Modes  of  action,  656.  Dan- 
gers attending  its  use,  657. 


XIV  CONTENTS. 

CHAPTER   XL. 

SURGICAL  TREATMENT. 

Removal  of  polypoid  tumors,  658.  Enucleation,  663.  Laparotomy,  667. 
Laparo-hysterectomy,  668.  Oopliorectomj' — Battey's  operation  —  spaying, 
673.     Operation,  678.     Physical  and  psychical  results,  680. 

CHAPTER   XLI. 

AFFECTIONS  OF  THE  OVARIES. 

Congenital  atrophy,  682.  Hypertrophy,  682.  Displacement,  682.  SjTuptoms, 
684.  The  diagnosis,  684.  Causes,  685.  Effects,  685.  Prognosis,  685. 
Treatment,  685.  Acute  ovaritis,  688.  Treatment,  689.  Chronic  ovaritis — 
ovarian  irritation,  689.  Etiology,  690.  Symptoms,  691.  Diagnosis,  692. 
Prognosis,  693.     Complications,  693.     Treatment,  693. 

CHAPTER   XLII. 

AFFECTIONS  OF  THE  OVARIES CONTINUED.       OVARIAN  TUMORS. 

Anatomy,  695.  Theories  of  their  origin,  704.  Modes  of  termination,  710. 
Causes,  712.  Prognosis,  713.  Diagnosis,  714.  Remarks  on  diagnosis  of 
ovarian  tumors  generally,  714.  Physical  examination,  715.  Palpation  and 
percussion,  716.  Exploration,  719.  "  On  the  granular  cell  found  in  ovarian 
fluid, ' '  720.     Differential  diagnosis,  723. 

CHAPTER   XLIII. 

OVARIAN  TUMORS  —  CONTINUED. 

Treatment,  730.  Curative  treatment,  736.  Surgical  treatment,  736.  Injection 
of  the  sac,  740.     Electrolysis,  745.     Vaginal  ovariotomy,  746. 

CHAPTER  XLIV. 

ABDOMINAL  OVARIOTOMY. 

General  observations,  748.  Treatment  of  the  pedicle,  748.  The  ligature,  749. 
Drainage,  750. 

CHAPTER  XLV. 

ABDOMINAL  OVARIOTOMY CONTINUED. 

Preparation  of  the  room,  761.  Preparation,  761.  Oixiration,  762.  Second 
step,  764.     Ovariotomy,  765.     Third  step,  769. 


CONTENTS.  XV 

CHAPTER   XLVI. 

OVARIOTOMY CONTINUED. 

Accidents  that  may  occur  during  the  operation,  771. 

CHAPTER  XLVII. 

OVARIOTOMY CONTINUED. 

After-treatment,  774.  Treatment  of  the  wound,  775.  Attention  to  clotliing, 
775.  Vomiting,  776.  Tympanites,  777.  Hemorrhage,  778.  Traumatic 
peritonitis,  779.  Septicaemia,  781.  Treatment,  782.  Remarks,  783. 
Tumor  of  the  broad  ligament,  or  parovarian  tumor,  784.  Etiology,  785. 
Symptoms,  785.     Diagnosis,  785.     Prognosis,  786.     Treatment,  786. 

CHAPTER  XLVIII. 

FALLOPIAN  TUBES. 

Salpingitis,  789.  Symptoms,  790.  Diagnosis,  791.  Prognosis,  792.  Treat- 
ment, 792.     Surgical  treatment,  795.     Hemato-salpinx,  796. 

CHAPTER  XLIX. 

COCCYGODYNIA,  COCCYALGIA. 

Neuralgia  of  the  coccyx,  798.  Structure  affected,  798.  Symptoms,  798.  Diag- 
nosis, 799.     Prognosis,  799.     Treatment,  799. 


INDEX  OF  ILLUSTRATIONS. 


Fig.    1.  Sagittal  section  of  pelvic  organs  in  the  virgin,  .         .         .    Byford 

"      2.  Sagittal  section  of  pelvic  organs  of  child-bearing  woman, 
"      3.  Position  of  the  uterus  when  the  bladder  is  full, 
"      4.  Schematic  representation  of  the  ligaments  about  the  internal 

OS  uteri, 

"      5.  Round  ligament,       ......... 

"      6.  Schematic  representation  of  round  ligaments, 

"      7.  Coronal  section  of  the  pelvis, Luschka 

"      8.  Sagittal  section  of  the  pelvic  connective  tissue,         .      Wm.  A.  Freund 
"      9.  Horizontal  section  of  pelvic  connective  tissue, 

"  10.  Position  of  the  ovaries, Schultze 

"  11.  Relation   of   ovary  to   posterior  surface  of   broad   ligament, 

Modified  from  Henle 

'    "  12.  Positions  of  ovaries  and  Fallopian  tubes, Byford 

"  13.  Manner  of  insertion  of  the  cervix  uteri  into  the  vagina, 

"  14.  Horizontal  section  of  pelvic  floor  near  the  pelvic  outlet,  .      Henle 

"  15.  Internal  obturator  muscle,     .  .         .         .        .   Tarnier  and  Chant reuil 

"  16.  Pelvic  floor  outlet,  Byford 

"  17.  Pubic  attachments  of  the  levatores  ani  et  vaginae  muscles,       .     Savage 

"  18.  Muscles  of  the  pelvic  floor, 

"  19.  Horizontal  section  of  pelvis, 

"  20.  Illustration   of  the   action   of  abdominal   pressure   upon  the 

uterus, Byford 

"  21.  Voluntary  contraction  of  the  pelvic  floor  during  straining  and 
lifting,       ........■• 

"  22.  Perineal  muscular  system.     (Schematic),         .         .         .         . 

"  23.  Dissection  of  the  muscles  of  the  perineum  and  pelvic  floor,      .    Savage 

"  24.  Perineal  fascia  laid  open, 

"  25.  Pelvic  floor  and  perineal  fasciae, Byford 

\     "  26.  Perineal  triangles  of  virgin, 

"  27.   Of  married  nullipar, 

"  28.  Of  old  woman, 

"  29.  Of  old  maid  before  menopause, 

"  30.   Shape  of  relaxed  perineal  triangle, 

"  31.  Relations  of  muscles  and  fasciae  to  perineal  body,     . 

"  32.  Folding  of  the  perineal  body  in  normal  labor, 

"  33.  Flattening  of  the  perineal  body  in  labor, 

B 


XVlll 


INDEX    OF    ILLUSTRATIOXS. 


Byford 


Luschka 
Hyrtl 

Sargent 

Byford 


Fig.  34.  Muscular  fibres  of  rectum, 

"    35.  Distended  rectum, 

"    36.  Relation  of  the  ureters  to  tlie  bladder  and  uterus,    . 
"    37.  Distribution  of  the  ovarian,  uterine  and  vaginal  arteries 
"    38.   Operating  chair,      ....... 

"    39.  Byford' s  operating  table,      ■ 

"    40.   Position  for  Sims's  speculum,  .... 

"    41.  Virgin  uterus  and  vagina, 

"    42.  Uterus  of  the  child-bearing  woman, 

"    43.   Senile  uterus  and  vagina,  ...         .... 

"    44.  Digital  examination  in  the  dorsal  position,       .         .         .         .         ' 

"    45.  Bimanual  palpation  of  the  uterus  from  the  posterior  vaginal 

v^'all, •       • 

"    46.  Bimanual  palpation  of  the  uterus  through  the  anterior  vaginal 
fornix,       ........  .         • 

"    47.  Uterus   artificially  turned   back  against  the    hollow    of   the 
sacrum,  for  palpation  of  the  posterior  wall,       ... 
"    48.  Positions  of  ovaries  as  seen  from  the  pelvic  brim,    Modified  from  Schultze 
"    49.  Artificial  tension  of  the  round  ligaments,  using  the  sacro-uterine 

attachment  as  a  fulcrum,  .......    Byford 

"    50.  Position  of  the  uterus  produced  by  contraction  of  the  round 
ligaments,  ......... 

"    51.  Position  of  the  ureters.     (Schematic), 

"    52.  Uterine  torsion  produced  by  contraction  of  the  sacro-uterine 

ligament  of  one  side,  ....    Modified  from  Schultze 

"    53.  Position  of  uterus  produced  by  contraction  of  the  sacro-uterine 

ligaments, 

"    54.  Method  of  introducing  the  finger  into  the  rectum,   . 

"    55.  Bimanual  examination  of  the  posterior  surface  of  the  uterus 

and  the  posterior  pelvic  spaces  from  the  rectum, 
"    56.  Recto-vaginal  grip  of  the  retroverted  uterus,  .... 
"    57.  Bimanual  circumdigitation  from  the  rectum  and  vagina,  . 

"    58.  Palpation  of  the  uretral  orifices, 

"    59.  Grasping  the  coccyx, 

"    60.  Anterior  surface  of  the  sacrum, 

"    61.   Vaginal  entrance  of  the  virgin, 

"    62.   Vaginal  entrance  of  the  married  nullipar,         .... 
"    63.  Vaginal  entrance  of  the  married  nullipar,  with  contracted  or 

short  levator  ani, 

"    64.  Vaginal  entrance  with  greatly  relaxed  or  destroyed  levator 
vaginse,     ........•• 

"    65.   Same  as  above,  except  that  the  levator  ani  is  short, 

' '    66.  Shape  of  vulval  orifice,    . 

"    67.  Same,  of  married  nullipar, 

"    68.  Same,  of  child-bearing  woman, 

"    69.  Simpson's  sound,     . 

"    70.  Sims's  sound,  .... 

''    71.  Jenks's  uterine  probe, 

"    72.  Fitch's  measuring  sound, 

"    73.  Introduction  of  the  uterine  sound, 


Byford 


Winckel 

Byford 

Gray 

Byford 


Trnax 


Byford 


IXDEX    OF    ILLUSTEATIONS. 


XIX 


Fiff.    7 


4. 

75. 
76. 
77. 
78. 
79. 
80. 
81. 
82. 
83. 
84. 
85. 
86. 
87. 
88. 
89. 
90. 
91. 
92. 


93. 

94. 

95. 

96. 

97. 

98. 

99. 
100. 
101. 
102. 
103. 
104. 
105. 
107. 
108'. 
109. 
110. 
111. 
112. 
113. 
114. 
115. 
116. 
117. 
118. 
119. 
120. 
121. 
122, 


the  side, 

s  method  of  examining  the 


Byford 

Truas 
Sargent 


Tiemann 

Byford 
Truax 


Sargent 


Hysterometer, 

Method  of  applying  hysterometer, 

Higby's  speculum, 

Nott's  speculum,    . 

Nelson's  speculum,  closed, 

Nelson's  speculum,  open. 

Nelson's  tenaculum, 

Double  tenaculum  forceps, 

Tenaculum  forceps, 

Speculum  introduced,     . 

Dressing  forceps,    . 

Sims' s  speculum,    . 

Sims' s  depressor,    . 

Tenacula,        .... 

Nott's  tenaculum  forceps, 

Simon's  speculum, 

Simon's  retractors, 

Lever  for  dilating  the  vagina  from 

Action  of  the  instruments  in  Sims 

uterus,       .... 
Sponge  tent,  .... 
Laminaria  tent, 
Tupelo  dilators  (hollow), 

Compressed  slippery- elm  tents,  straight  and  carved 
Compressed  slippery-elm  tent,  hollow,  . 
Tent  mounted  on  tent-holder, 
Molesworth's  dilator,      .... 

Hanks'  dilators, 

Probe  curette,         ..... 

Thomas's  wire  curette,    .... 

Byford 's  finger  curette,  .         .         .         . 

Sims's  sigmoid  catheter, 

Groodman-Skene's  self- retaining  catheter, 

Skene's  urethral  endoscope,   .......  Tiemann 

Simon's  urethral  catheter, Winckel 

Elephantiasis  of  the  labia, Scanzoni 

Cancer  of  the  labia, McClintock 

Folding  of  the  perineal  body  in  normal  labor,         .         .         .    Byford 
Flattening  of  the  perineal  body  due  to  rigidity. 
Diagonal  flap  laceration  of  perineum,  left  side, 

Triangular  lacerations  of  the  perineum, 

Diagonal  lacerations  of  the  perineum,    . 
Diagonal  bilateral  laceration  with  vulval  extension 
Same,  with  extension  into  the  rectum,    . 
Double  diagonal  and  transverse  laceration, 
Same,  with  both  vulval  extension  and  transverse, 
Degrees  of  median  laceration  through  perineal  raphe, 
Degrees    of  extension   of  diagonal  laceration  through   the 
raphe, 


Byford 
Sargent 

Tiemann 
,    Truax 

a 

Sargent 

u 

Truax 


XX 


INDEX    OF    ILLUSTRATIOXS. 


Fig.  123. 

"  124. 

"  12.5. 

"  126. 

"  127. 

"  128. 

"  129. 

"  1.30. 

"  131. 

"  132. 

"  133. 

"  1.34. 

"  135. 

"  136. 

"  137. 

"  138. 

"  139. 

"  140. 

"  141. 

"  142. 

"  143. 

"  144. 

"  145. 

"  146. 

"  147. 

"  148. 

"  149. 

"  150, 

"  154. 

"  155. 

"  ].56. 

"  1.57. 

"  158. 

"  159. 

"  160. 

"  161. 

"  162. 

"  163 

"  165, 

"  166, 

"  167, 

"  168, 

■'  169, 


Deformity  produced  bj'tlie  traDSverse  or  deep  double  diagonal 
laceration.  ....... 

Incisions  to  be  made  in  perineal  tenotomy,     . 

Perineal  tenetome,  double,     ..... 

Deep  suture  entered  near  edge  of  wound. 

Deep  suture  entered  at  a  distance  from  edge, 

Edges  of  wound  pared  to  prevent  compression, 

Fla]3  stitcli,    ........ 

Triangular  denudation  of  perineum.     (Schematic), 

3Iodified  triangular  denudation  of  perineum, 

x\ppearance  of  the  modified  triangular  denudation  between 
separated  labia,      .  ..... 

Bilateral  denudation  with  stitches  passed. 

Same,  with  vaginal  stitches  tied,    .... 

Martin's  modification  of  the  bilateral  denudation,  . 

Crescentic  denudation  with  vaginal  stitches  passed, 

Same,  with  vaginal  stitches  tied,    .... 

Crescentic,  modified,       ...... 

[  Star  denudations,  .         .         . 

Lines  of  incision  in  triangular  flap  operation, 
Same,  with  flaps  raised  and  sutures  passed,    . 


Byford 

Truas 
Bvford 


Zweifel 
Byford 

u 

jNIartin 
Bvford 


Hart  and  Barbour 


Bvford 


f  Denudation,  as  made  by  Bishofi",  .... 

Unilateral  flap  denudation, " 

Hegar's  triangular  denudation, Hegar 

Freund's  bilateral  denudation,         .....         Kuestner 

Triangular  flap   operation,  applied  to  lacerations   extending 

into  the  rectum,         ......  Hart  and  Barbour 

Same,  with  flaps  raised  and  stitches  passed,    .        .         "  " 
151,  152  and  153.  Unilateral  flap  operations  applied  to  lacera- 
tions extending  into  the  rectum,        .....  Byford 

Emmet's  method  of  passing  sutures  in  lacerations  deep  into 

the  recto-vaginal  septum,          .....         .  Emmet 

Splitting   of  perineum   and  flap   stitches   passed   after  the 

manner  of  Lawson  Tait, Zweifel 

Perineum  scissors, Truax 

Langenbeck  serres-fine  for  compressing  arteries,     .         .         .  " 

Silver  sutures,  properly  bent,          ......  Byford 

Silver  sutures  twisted  without  being  properly  bent,         .         .  " 

Method  of  securing  twisted  ends  of  silver  sutures,          .         .  Emmet 

Quilled  sutures,  tied, Zweifel 

Skene's  double  perforated  catheter, Truax 

and  1 64.  Urinary  fistulte,          .......  Byford 

Tenaculum,  with  which  to  hold  the  edge  of  fistula  while  being 

pared,        ..........  Sargent 

Curved  scissors,  for  paring  edge  of  fistula,      .         .         .         .  " 

Wire  adjuster,        .........  " 

Speculum,  for  dilating  vagina,        .         .         .         .         .         .  " 

Forceps,  for  twisting  the  wires,       .         .         ...         .         .  " 


IXDEX    OF    ILLUSTEATIOXS. 


XXI 


Fig.  170.  The  catheter, Sargent 

"    171.  Needle  forceps,       ...... 

"    172.  Sponge-holder.     The  instruujents  are  represented  half-size, 

"    173.  Method  of  paring  the  edges  of  a  urinarj' fistula,    .         .         .    Byford 

"    174.  Method  of  passing  the  needle, 

"    175.  Method  of  using  the  tenaculum,  etc. ,     . 

"    176.  The  fistula,  with  edge  pared  and  sutures  placed, 

"    177.  Wire  adjuster, 

"  178.  Twisting  the  wire  sutures,  .... 
"  179.  RemoAnng  the  sutures,  ..... 
"    180  to  185.  Simon's  method  of  operating  upon  urinary  fistula,       .      Simon 

"    186  and  187.  Kolpoklesis, 

"    188.  Bozeman's  apparatus, Bozeman 

"    189.  Bozeman's  button,  .         .         .         . 

"    190.   Same,  with  sutures  tied,         .... 

"    191.  Strong  retroflection,  favoring  gravitation  to  the  fundus,         .    Bj-ford 

"    192.  Retroflexed  uterus,  with  fundus  raised  by  a  pessary, 

"    193.  Sims's  method  of  dividing  the  cervix, Sims 

"    194.  Emmet's  knife,  for  dividing  the  cervix, Emmet 

"    195.  Division  of  the  flexed  cervix, Sims 

"    196.  Peaslee's  metrotome, Peaslee 

"    197  to  200.  Uterine  cavity  after  different  methods  of  division 

"    201.  Goodell's  uterine  dilator, Truas 

"    202.  Fountain  syringe  and  douche  pan, 

"    203.   Ointment  syringe,  ..... 

."    204.  Uterine  scaiificat or, Sargent 

"    205.  Dr.  Buttle's  uterine  scarificator  and  leech,     ....      Truax 

"    206.  Slippery-elm  tent, Byford 

"207.  Slippery-elm  tent,  introduced, 

"    208.   Same  introduced  in  case  of  anteflexion, 

"    209.  The  cervix,  with  threads  passed,    . 

"    210.  Lacerated  cervix,  after  denudations, Emmet 

"    211.  Byford's  uterine  scissors, Sargent 

"    212.  Mode  of  passing  the  sutures, Byford 

"    213.  The  sutures  properly  placed  and  twisted, 

"    214,215.  Hypertrophy  of  the  cervix  uteri,     . 

"    216.  Supravaginal  elongation  of  the  cervix,   . 

"    217.  Amputation  of  the  cervix  by  Sims's  method,  .         .         .        Sii 

"    218.  Same,  with  sutures  tied,         .... 

"    219.  Amputation  of  cervix,  bj'  Simon's  method,    ....      Simon 

"    220.  Stoltz's  denudation  for  cystocele, Munde 

"    221.  Pathological  changes  in  location  of  the  uterus.     Dislocations,    Bj'ford 
"    222.  Pathological  anteflexion  caused  by  shortening  of  the  sacro- 
uterine ligaments,      .......  Schultze 

"    223.  Anteflexion,  produced  by  a  contraction  of  the  round  ligaments,    Byfird 

"    224.  Puerile  anteflexion, Schultze 

"    225.  Anteflexion,  with  retrolocation  and  retroversion,    .         .         .    Byford 

"    226.  Extreme  retroflexion  of  the  uterus, 

"    227.  Natural  position  of  the  body, 

"    228.  Unnatural,  or  stooping  position  of  the  body, 


XX 11 


IXDEX    OF    ILLUSTRATIONS. 


Fig. 


229. 
230. 
231. 
232. 
233. 
234. 


236. 
237. 
2.38. 
239. 
240. 
241. 
242. 
243. 
244. 
245. 
246. 
247. 
248. 
249. 
2.50. 
251. 
252. 
253. 
254. 


256. 
257. 
258. 
259. 
260. 
261. 
262. 
263. 
264. 
265. 

266. 
267. 

268. 

269. 
270. 
271, 
273. 


Antevevsion  and  retroversion, 

Anteflexion  and  retroflexion, 

Soft  rubber  inflated  pessaries, 

Peaslee's  elastic  ring. 

The  Sims-Emmet  denudation  for  C3"Stocele  and  procidentia 

Lateral  denudation  in  the  uretliral  fossae  and  anterior  vaginal 

sulci,  ........ 

Denudation  for  raising  and  strengthening  the  whole 

vaginal  septum, 

Suture  passed  so  as  to  catch  up  the  bottom  of  the  wound, 

Same,  united,         ..... 

Suture  passed  and  tied  in  the  usual  manner, 

Fitch  supporter,      .... 

Silk  elastic  belt,      .... 

Schultze's  sleigh  pessary, 

Zwank's  pessary,    .... 

Mcintosh  uterine  supporter, 

jMcIntosh  supporter  applied, 

Thomas's  modified  Cutter  pessary, 

Scott's  pessary,       .... 

Pessary,  with  tapes  for  attachment  to  a  belt, 

Outlines  of  denudation  for  procidentia,  . 

Denudation  for  procidentia,  after  Fritsch, 

Denudation  for  procidentia,  after  Ileamj", 

Grehrung's  pessar}'  for  anteversion, 

Hewitt's  antevei'sion  i)essary, 

Thomas's  anteversion  i>essary, 

Bj'ford's  pessary,  with  the  neck   elevated,  for  the  relief  o 

anteversion,       .... 
Anteversion  pessary,  acting  by  holding  the  lower  end  of  th 

cervix  forward,  .... 

Byford's  retroversion  pessary, 
Byford's  retroversion  and  prolapse  pessary, 
Byford's  retroversion  pessary  in  place,   . 
The  Albert  Smith  retroversion  pessary, 
Hodge's  closed  lever  pessary, 
Hewitt's  cradle  pessary,  .         . 

Thomas's  retroflexion  pessarj'. 

Fowler's  pessary, 

H.  Marion  Sims's  retroversion  stem  pessary, 

Needle  mounted  upon  needle-holder,  for  introducing  sutures 

into  the  sacro-uterine  ligaments, 
Byford's  probe-pointed  scissors  for  cutting  fascia, 
Byford's  broad  hook,      ..... 
Curves  of  posterior  vaginal  walls,  after  a  poorly  ])erf 

perineon-haph}',         .... 
Jackson's  intra-uterine  stem, 
Thomas's  bulb  retroflexion  pessary,  elastic, 
272.  White's  repositor,  .... 
Beduction  of  inversion  by  the  elastic  bagt 


Schultze 

Byford 
Truax 

Bvford 


Tiemann 

u 

Triiax 
Sargent 


Truax 

Sargent 
Byford 
Winckel 
Fritsch 
Beamy 
Sargent 
Tiemann 


Bvford 


Truax 

Byford 

Sargent 

Truax 

Reynders 
Truax 

Ford 

Byford 
Truax 


Byford 

Truax 

Sargent 

Tiemann 

Bvford 


INDEX    OF    ILLUSTRATIONS. 


Fig.  274.  Sharp  curette, 

"  275.  Simon's  curette,    .         .         .      ■ 

"  276.  Epithelioma  of  uterus, 

"  277.  Epithelioma  of  the  cervix, 

"  278.   Fungus  growing  from  the  cervix, 

"  279.   Structure  of  epithelioma, 

"  280.  Dr.  Paquelin's  thermo-cautery, 

"  281.  Byrne's  cautery  battery, 

"  282.  Byrne's  cautery  ecraseur, 

"  283.  Byrne's  cautery  electrodes,     . 

"  284.  Structure  of  sarcoma,    . 

"  285.  Origin  of  fibroid  tumors, 

"  286.  Fibroid  polypus,     . 

"  287.  Submucus  fibroid  tumor, 

"  288.   Sub-peritoneal  fibroid  tumor, 

"  289.  Intramural  fibroid  tumor, 

"  290.  Chassaignac's  ecraseur, 

"  291.   Small  vulsellum  forceps, 

"  292.  Medium-sized  vulsellum  forceps, 

"  293.  Large  vulsellum  forceps, 

"  294.   Sims's  enucleator, 

"  295.   Sims's  guarded  hook,  to  aid  in  drawing 

"  296.  Thomas's  serrated  spoon, 

"  297.  Aspirator,      .... 

"  298.  Microscopic  examination  of  fluid  fr 

"  299.  Fitch's  trocar, 

'"  300.  Trocar, 

"  301.  Nekton's  forceps, . 

"  302.  Sponge  holder, 

"  303,304.  Rubber  coil,    . 

"  305,  306.  Enucleation  of  cysts  of  the  broad  ligament, 


Shepard  and  Dudley 
.    Byford 


Cornil  and  Ranvier 

Codman  and  Siiurtleff" 

Shepard  and  Dudley 


Cornil  and  Eanvier 
Byford 


Sargent 
Truas 


the  tumor, 


Codman 
om  ovarian  tumors. 


and 


Sargent 
Tiemann 


Shurtleif 

Atlee 

Sargent 


Truax 


Byford 


DISEASES  AND  ACCIDENTS 


INCIDENT  TO  WOMEN, 


CHAPTER    I. 


PEACTICAL  OBSEEVATIONS  UPON  THE  ANATOMY  AND  PHYSIOLOGY 
OF  THE  FEMALE  PELVIC  OKGANS. 


The  uterus  is  normally  situated  in  the  median  line  of  the  body, 
between  the  bladder  and  rectum,  just  below  the  pelvic  brim  (Figs.  1 


Fig.  1. 


Sagittal  Section  of  Female  Palvic  Organs  in  the  Virgin  (l/Q. 
U,  uterus ;  B,  bladder ;  R,  rectum  ;  pt,  perineal  triangle ;  pf,  perineal  floor ;  pfe,  perineal  floor 
edge ;  S,  symphysis  pubis  ;  P,  promontory  of  sacrum  ;  ppr,  plane  of  pelvic  roof;  prp,  pelvic  roof 
projection ;  ss,  superior  strait ;  ass,  axis  of  superior  strait. 

and  2).   It  is  often  found  so  twisted  upon  its  long  axis  as  to  bring  the 
left  side  a  little  farther  forward  than  the  right,  and  the  cervix  some- 

2 


18       AXATOMY    AXD    PHYSIOLOGY    OF    FEilALE    PELVIC    OEGAXS. 

what  to  the  left  of  the  median  position.  It  has  three  systems  of  sup- 
ports :  the  pelvic  roof,  or  the  sustaining  ;  the  pelvic  floor,  or  retaining ; 
and  the  perineum,  or  supplementary  support. 

I.  Pelvic  Eoof. 

The  pelvic  roof  is  formed  by  the  expansion  and  reduplication  of 
the  peritoneum  upon  and  between  the  pelvic  viscera,  with  whose 

Fig.  2. 


Sagittal  Section  of  Pelvic  Organs  of  Child-bearing  Woman  (}/Q. 
ij),  vaginal  promontory.    (See  Fig.  1  for  further  explanation.) 


walls,  and  the  circumposed  connective,  muscular,  vascular,  and 
glandular  tissues,  it  unites  to  form  an  exceedingly  elastic  and  per- 
fectly adec^uate  uterine  support.  These  duplicatures  or  folds  are 
called  the  pubo-uterine,  or  pubo-vesico-uterine,  in  front,  stretching 
from  the  pubes  to  the  anterior  surface  of  the  uterus ;  the  sacro-uterine 
or  sacro-recto-uterine  (folds  of  Douglas,  or  posterior  suspensory  liga- 
ments) behind,  passing  from  the  posterior  walls  of  the  uterus  and 
vagina  to  the  sacrum  ;  and  the  broad  ligaments  (ligamenta  lata,  alar 
ligaments)   on  the  sides  passing  across  the   anterior   and  posterior 


MUSCULATURE   OF    THE    PELVIC   ROOF. 


19 


uterine  surfaces  to  the  sacro-iliac  synchondroses  (Fig.  4) ;  and  the 
round  ligaments,  reaching  in  a  curve  from  the  sides  of  the  uterus 
near  the  fundus  forward  to  and  through  the  inguinal  canals. 

Musculature  of  the  Pelvic  Roof. 

The  round  ligaments  (Figs.  5  and  6)  are  muscular  cords  about  the 
size  of  a  large  goose-quill,  given  off  from  the  external  muscular  coat 


Fig.  3. 


Position  of  the  Uterus  when  the  Bladder  is  full  (H). 
ppr,  plane  of  pelvic  roof;  prp,  pelvic  roof  projection ;  ss,  superior  strait ;  ass,  axis  of  superior 
strait. 

of  the  uterus  under  the  Fallopian  tubes.  They  pass  a  short  distance 
between  the  layers  of  the  broad  ligaments,  emerge  from  their  anterior 
surfaces  to  enter  the  inguinal  canals,  where  they  receive  a  connective 
tissue  sheath.  A  portion  of  the  muscular  fibres,  with  others  from  the 
sheath,  form  an  intimate  attachment  to  the  external  pillar  of  the 
external  ring,  and  a  looser  attachment  to  the  internal  pillar,  while  the 
remainder  pass  on  to  the  pubic  bone.  The  connective  tissue  sheath 
affords  an  elastic  attachment  of  the  ligaments  througliout  the  canals. 
They  pursue  a  curved  course,  but  are  somewhat  straightened  and  put 
slightly  upon  the  stretch,  when  the  fundus  uteri  and  the  broad  liga- 


20      ANATOMY    AXD    PHYSIOLOGY    OF    FEMALE    PELVIC    ORGANS. 

ments,  or  either,  are  lifted  upwards  and  backwards  by  the  filling  of 
the  bladder,  or  by  improperly  applied  abdominal  or  other  pressure. 
Unless  misplacing  forces  have  acted  too  long  they  will  promptly  bring 
the  fundus  and,  to  a  certain  extent,  the  broad  ligaments  back  into 
normal  unconstrained  relationship  with  their  surroundmgs. 

Muscular  fibres  can  also  be  traced  from  the  bladder  and  uterus  into 
the  pubo-vesico-uterine  connective  tissue,  aiding  in  drawing  and  hold- 
ing the  cervix  sufiiciently  forward.     The  muscular  walls  of  the  base 


Fig.  4. 


Schematic  representation  of  the  Ligaments  about  ilie  Internal  Os  Uteri,  at  the  plane  of  the  pelvic 
roof.    Drawn  upon  Schultze's  diagram  of  the  female  pelvis,  one-third  the  natural  size.* 
E  P  M.,  edge  of  psoas  muscle;  B  B  L.,  base  of  broad  lig.;  I  O.,  int.  os.;  S  U  L.,  sacro-uterine  lig.; 
S  P  P.,  sacral  peritoneal  pouch. 

of  the  bladder,  and  particularlj'-  the  anterior  wall  of  the  vagina,  as 
long  as  the  intervening  connective  tissue  is  firm,  add  materially  to 
the  strength  of  these  anterior  supi^orts.  Quite  an  abundance  of  mus- 
cular tissue  also  extends  from  the  posterior  cervical  and  vaginal  walls 
under  the  sacro-uterine  folds  to  the  rectum,  to  the  periosteum  of  the 
second  sacral  vertebra,  and  to  the  neighboring  tissues.  Thus  strength- 
ened these  folds  reach  in  a  semicircle  partly  around  the  rectum,  and 
suspend  the  cervix  almost  directly  underneath  the  second  sacral 
vertebra,  in  such  manner  that  the  weight  of  the  corpus  with  the  trac- 
tion of  the  round  ligaments  acts  to  keep  the  fundus  over  the  bladder. 
Some  of  these  posterior  fibres,  with  others  from  the  uterus  and  vagina, 
also  run  into  the  broad  ligaments,  and  strengthen  them  in  their  lateral 
traction  upon  the  cervix  and  vaginal  walls.     Sometimes  they  form 


*  Schultze's  outline  6gures  of  the  pelvis  are  freely  copied  in  many  of  the  schematic 

drawings  in  this  book  as  being  the  best  and  most  available  for  the  purpose. 


MUSCULATURE    OF    THE    PELVIC    ROOF. 


21 


two  bands  :  one  passing  outward  in  front  of  the  vessels  and  nerves  to 
the  anterior  peritoneal  fold  of  the  ligament,  and  the  other  back  of  the 


p:l, 


0 


Round  Ligament  passing  under  the  anterior  layer  of  the  Broad  Ligament. 
P.L.,  round  ligament;  I. P.,  infundibulo-pelvic  ligament;  F.T.,  Fallopian  tube;  U,  uterus; 
0,  ovary  upon  opposite  side ;  M.S.,  meso-salpinx. 

vessels  and  nerves  to  the  posterior  fold  (William  A.  Freund).     The 
upper  portions  of  the  broad  ligaments,  held  forward  by  the  round 


Fig.  fi. 


Schematic  Representation  of  Round  Ligaments  {}/Q. 
a,  fundus  uteri  behind  symphysis  pubis:  6,  fundus  uteri  against  the  sacrum  ;  c,  fundus  uteri 
when  the  bladder  is  full ;  ov'^,  ovary  belonging  to  b ;  or^,  ovary  belongingto  a,  with  relaxed  round 
ligament;  oz;3^  ovary  belonging  to  a,  with  tight  round  ligament;  arc,  6rc.  cro,  round  ligament 
belonging  to  a,  b,  and  c,  represented  as  somewhat  contracted,  or  tense  ;  ar,  br,  cr,  round  ligament 
relaxed. 


22      ANATOMY    AXD    PHYSIOLOGY    OF    FEMALE    PELVIC    ORGANS. 

ligaments,  present  their  posterior  surfaces  to  the  superincumbent 
abdominal  viscera,  and  thus  also  tend  to  keep  the  ovaries  and  the 
fundus  .  uteri  forward.  It  is  not  improbable  that,  being  thus  elastic 
and  attached  to  the  sides  of  the  pelvis  a  little  behind  the  transverse 
central  diameter  (farther  back  on  the  right  than  left  side),  they  are 
rendered  sufficiently  tense,  when  the  bladder  is  empty,  to  help  hold 
the  fundus  up  from  the  vesico-vaginal  septum. 

Peritoneal  Covering  of  the  Pelvic  Roof. 

Behind  the  uterus  the  peritoneum  dips  below  the  vaginal  junction 
from  a  few  lines  to  an  inch  or  more  (Fig.  1),  forming  the  recto-uterine 
pouch  (cul-de-sac  of  Douglas),  and  is  reflected  back  upon  the  rectum, 
which  it  covers  from  this  level  upward.     Over  the  posterior  surface 

Fig.  7. 


Diagram  of  Coronal  Section  of  the  Pelvis  (Luschka). 
a,  peritoneal  cavity ;  h,  subperitoneal  cavity  ;  c,  ischio-rectal  fossa ;  d,  uterus. 


and  fundus  of  the  uterus  the  peritoneum  is  firmly  attached ;  on  the 
anterior  surface  it  becomes  less  firmly  adherent  as  it  passes  down, 
and  in  the  neighborhood  of  the  internal  os  where  it  is  reflected  over 
the  bladder,  forming  a  vesico-uterine  pouch,  permits  itself  during 
filling  of  that  viscus,  during  pregnancy,  and  in  some  pathological 
conditions,  to  be  strijDped  from  both  the  uterine  and  vesical  surfaces 


PELVIC    CONNECTIVE   TISSUE. 


23 


for  quite  a  distance.  Between  the  bladder  and  anterior  abdominal 
wall  the  peritoneum  does  not  reach  down  quite  as  low  as  the  upper 
edge  of  the  symphysis  pubis,  is  loosely  attached  here  also,  and  may 
be  stripped  from  its  lower  connections  the  same  as  between  the  bladder 
and  uterus.  Under  favoring  conditions  it  allows  the  bladder  and 
vagina  to  be  approached  extra-peritoneally  through  the  abdominal 
walls.  At  the  time  of  parturition  the  peritoneum  is  said  to  be  entirely 
separated  from  the  bladder  (Hart).  Behind  the  broad  ligaments — in 
the  sacral  pouches — the  peritoneal  cavity  reaches  down  to  about  the 
level  of  the  internal  os ;  in  front  of  them  in  the  para-vesical  pouches 
it  does  not  dip  quite  so  low. 

Pelvic  Connective  Tissue. 
As  connective  or  fibrous  tissue  exists  everywhere  in  the  body,  form- 
ing one  continuous  network,  penetrating  and  surrounding,  strength- 

FlG.  8. 


Sagittal  Section  of  Pelvis  through  the  Connective  Tissue  Chamber,  tlirough  Left  Broad  Liga. 
ment  near  the  Uterus,  cutting  off  a  corner  of  the  Bladder  and  of  the  Left  Vaginal  Fornix  (W.  A. 
Freund). 

ening  and  supporting  the  various  structures,  it  naturalh''  plaj^s  an 
important  part  in  the  pathology  of  the  pelvic  organs.     It  exists  in 


24      ANATOMY    AND    PHYSIOLOGY    OF    FEMALE    PELVIC    ORGANS. 

small  quantities  everywhere  under  the  peritoneum  ;  in  larger  quanti- 
ties between  the  bladder  and  the  symphysis  in  the  median  line,  along 
the  vesico-vaginal  septum,  between  the  bladder  and  uterus,  and  be- 
tween the  layers  of  the  broad  ligaments ;  while  under  the  sacro-uterine 


Fig.  9. 


2m7  Scixral  VertehvO' 


Ccnriectt^e  Tcssu^ 
zive  Tissue 


Tfreierr 


cgy-v/x    s, 
Ut&rL  ^ 


Slaiktsr 


Pitbis 


Horizontal  Section  of  Pelvis  through  the  Second  Sacral  Vertebra  and  Pubis  (W.  A.  Freuud). 


and  broad  ligaments  on  either  side  it  is  so  abundant  as  to  form  a  large 
connective-tissue  chamber  (Figs.  7,  8,  9). 

These  chambers  are  Ijounded  above  by  the  reflected  peritoneal  folds 
of  the  broad  ligaments  over  the  para-vesical  and  sacral  pouches,  below 
by  the  levatores  ani  and  coccygei  muscles,  internally  by  the  rectum, 
vagina,  cervix  and  base  of  the  bladder,  posteriorly  by  the  sacrum,  an- 
teriorly by  the  pubes  and  superior  attachments  of  the  levator  ani,  and 


THE    OVARIES    AND    THEIR   RELATIONS.  25 

laterally  by  the  iliac  bones  and  upper  edge  of  the  obturator  internus. 
More  properly  speaking,  there  is  only  one  such  subperitoneal  connec- 
tive tissue  chamber  which  extends  across  the  vesico-vaginal  septum 
and  contains  the  cervix,  vagina,  rectum  and  base  of  the  bladder  in  its 
centre.  Fig.  8  represents  a  sagittal  section  on  the  left  side  of  the 
uterus ;  Fig.  9  represents  half  of  a  horizontal  section  through  the 
second  sacral  vertebra  and  pubes.  The  extent  of  the  chamber  is 
shown,  although  the  shape  and  relationship  of  parts  is  not  exactly 
such  in  the  living  body. 

Innumerable  bloodvessels,  nerves  and  lymphatics  traverse  this  tis- 
sue in  every  direction,  to  and  from  the  different  organs  and  structures, 
and  depend  upon  its  integrity  for  the  healthy  performance  of  their 
functions. 

About  the  cervix  the  connective  tissue  contains  no  fat  but  receives 
muscular  fibres  from  the  uterus,  rectum  and  bladder,  and  is,  there- 
fore, unusually  elastic  and  displaceable,  allowing  the  cervix  to  be 
moved  in  every  direction  without  violence.  This  is  the  parametrium 
of  Virchow.  Around  the  pelvic  walls  the  connective  tissue  contains 
an  abundance  of  fat  which  gradually  diminishes  in  quantity  toward 
the  centre.  In  front  and  at  the  sides  it  disappears  abruptly  at  the 
ureters.  The  fat  adds  to  the  firmness  of  the  tissue,  and,  hence,  to  its 
supporting  and  resisting  power;  but  it  diminishes  its  elasticity  and 
thus  increases  its  liability  to  contusion  and  laceration  from  great 
violence. 

About  the  pelvic  viscera  the  connective  tissue,  receiving  fibres  from 
them,  becomes  more  dense  so  as  to  form  a  sort  of  sheath  (hohlcylinder 
of  W.  A.  Freund)  or  external  fibrous  coat ;  about  the  muscles  it  is 
condensed  into  firm  fascia  and  tendon,  and  supports  muscular  con- 
traction. 

In  fleshy  people  the  abundance  of  fat  renders  the  whole  connective 
tissue'  stronger  and  less  elastic  without  strengthening  the  fascise  ;  while 
in  people  of  great  muscular  development  the  fascise  become  firm,  and 
the  connective  tissue,  although  less  resistant  and  rigid  than  when  over- 
filled with  fat,  is  more  powerfully  retractile  and  better  capable  of  normal 
and  vigorous  function.  In  the  young  adult  female  there  is  usually  an 
abundance  of  fat  in  the  tissue,  combined  with  great  elasticity  of  fascia, 
producing  a  condition  of  strength  and  retractility  ;  in  the  middle-aged 
nullipara  there  is  usually  an  increase  of  fat  and  a  progressive  harden- 
ing of  the  fascia,  producing  a  condition  of  great  strength  and  rigidity ; 
in  the  aged  there  is  an  absorption  of  fat  and  a  shrinking  of  the  fascia, 
diminishing  the  strength  but  increasing  the  rigidity  (or  brittleness)  of 
the  tissue. 

The  Ovaries  and  their  Relations. 

The  ovaries  lie  on  the  posterior  surfaces  of  the  broad  ligaments  with 
their  long  axes  inclined  from  their  lateral  attachment  to  the  psoas 


26       ANATOMY   AND    PHYSIOLOGY    OF    FEMALE    PELVIC    ORGANS. 

fascise,  forwards  and  inwards  towards  the  symphysis.  Schultze's 
schematic  representation  (Fig.  10)  shows  the  position  in  which  I  have 
frequently  found  them.  Yet  I  have  also  found  them  sagging  down 
or  back  a  little,  or  swinging  a  trifle  around  their  external  attachments 
even  in  cases  of  normally  placed  uteri,  and,  therefore,  think  that  their 


Fig.  10. 


rip 


Position  of  tlie  Ovaries  (after  Sehultze)  (V^). 
0,  fundus  of  uterus  behind  pubes  ;  6,  fundus  when  the  bladder  is  full ;  c,  sacrum  ;  ap,  anterior 
superior  spine  of  ileum  ;  ps,  edge  of  psoas  muscle  ;  ip,  infundibulo-pel^ic  ligament ;  ov^,  nor- 
mally placed  ovary  ;  ov",  ovary  drawn  back  into  the  hollow  of  the  sacrum  by  displaced  fundus 
uteri ;  (yifi,  ovary  drawn  back  beside  cervix  by  the  replaced  fundus  ;  ov^,  ovary  pressed  or  held 
forward  when  fundus  is  back ;  ft,  Fallopian  tube ;  ol,  ovarian  ligament. 

position  is  within  physiological  limits  a  slightly  variable  one,  and  is 
affected  b}^  abdominal  pressure,  and  by  temporary  alterations  in  the 
conditions  and  relations  of  the  abdominal  and  pelvic  viscera.  Fig.  11 
represents  the  broad  ligament  and  its  contents,  modified  from  Henle. 
Sehultze  teaches  that  the  ovarian  ligaments,  which  pass  from  the 
anterior-inner  end  of  the  ovaries  to  the  uterus  just  below  the  Fallopian 
tubes,  and  are  four  inches  across  (including  the  uterus),  do  not  change 
the  position  of  the  ovaries  during  lifting  of  the  fundus  by  the  filling  of 
the  bladder  (Fig.  10).  But  when  the  fundus  leans  back  against  the 
sacrum,  the  anterior  inner  ends  of  the  ovaries  are  drawn  to  the  back 
part  of  the  pelvis ;  they  pass  from  ov"  to  qv\  The  infundibulo-pelvic 
ligaments  (Fig.  11)  or  outer  upper  end  of  the  broad  ligaments  are 
folds  of  peritoneum  extending  from  the  Fallopian  tubes  and  ovaries  to 
the  pelvic  wall,  and  contain  a  little  fibrous  tissue,  which  passes,  some- 
times in  visible  quantities,  upward  uj^on  the  outer  surface  of  the  peri- 
toneum. They  limit  the  motion  of  the  peripheral  end  of  the  ovary 
and  the  fimbriated  extremity  of  the  tubes  to  a  small  area  at  the  sides 
of  the  pelvis  (Figs.  10  and  12).     Ov^,  Fig.  10,  indicates  the  position  of 


URETERS. 


27 


the  ovaries  as  dragged  back  by  the  replaced  fundus  before  the  abdomi- 
nal pressure  has  had  an  opportunity  to  press  the  broad  ligaments  for- 
ward. On  account  of  the  looseness  of  attachment  of  the  peritoneum 
to  the  psoas  and  iliac  muscles,  the  infundibulo-pelvic  ligament  may 
be  drawn  out  so  as  to  allow  the  ovary  to  get  away  from  the  pelvic 
wall  even  into  the  recto-uterine  pouch.     (See  Fig.  48  ou*.)* 

The  Fallopian  tube,  being  too  long  for  the  space  it  occupies,  pursues 
an  undulating  course  and  floats  loosely  at  the  pelvic  brim,  over  the 

Fig.  11. 


'Relation  of  Ovary  to  Posterior  Surface  of  Broad  Ligament  (modified  from  Henle). 
1,  infundibulo-pelvic  ligament. 

meso-salpinx — that  part  of  the  broad  ligament  between  it  and  the 
ovary  and  ligament  behind,  and  the  uterine  end  of  the  round  liga- 
ment in  front  (Figs.  5,  8  and  11). 

Thus  while  the  lower  or  cervical  portions  of  the  broad  ligaments 
are  somewhat  resilient  and  act  the  part  of  true  supports  to  the  cer- 
vical end  of  the  uterus,  their  upper  portions  are  somewhat  volumi- 
nous and  movable  and  do  not  act  efficiently  until  the  fundus  falls  far 
forward  or  backward. 

Ureters. 

The  ureters  enter  the  base  of  the  bladder  at  the  basal  angles  of  the 
trigone,  an  inch  apart,  and  are  connected  by  a  continuation  of  their 
own  structure  (Garriguez)  forming  the  inter-uretric  ligament  (see  Fig. 
36).     They  pass  (as  traced  from  the   bladder  toward  the  kidneys) 


*  See  "  How  to  Palpate  the  Ovaries,"  chap.  TI.,  p.  59. 


28      ANATOMY   AXD    PHYSIOLOGY   OF    FEMALE    PELVIC    ORGANS. 

divergingly  backward  for  about  three-fourths  of  an  inch  between  the 
coats  of  the  bladder  to  emerge  from  one  and  a  half  to  two  inches  apart 
and  from  one-half  to  three-fourths  of  an  inch  in  front  of  the  cervix 
(Savage).  From  their  points  of  emergence  they  pass  in  slight  curves 
backward,  outward  and  upward,  under  and  behind  the  bases  of  the 
broad  ligaments,  near  the  spina  ischia.  They  then  turn  sharply  up- 
ward, behind  the  external  attachments  of  the  ligaments  and  external 
to  the  internal  iliac  arteries,  pass  up  behind  the  lateral  sacral  perito- 

FiG.  12. 


Positions  of  Ovaries  and  Fallopian  Tubes  when  the  Fundus  a  is  behind  the  Pubes  ;  and  b 
when  against  the  Sacrum  (^). 
oyi,  ovary  and  Fallopian  tube  held  normally  forward  with  a;  ov^,  ovary  and  tube  pressed  back 
while  a  is  held  forward  ;    ov^,  ovary  and  tube  carried  back  with  6 ;    ov^,  ovarj-  and  tube  held 
forward  while  b,  to  which  they  belong,  is  back  against  the  sacrum. 

neal  pouches,  across  the  anterior  surface  of  the  external  iliac  and 
behind  the  sigmoid  flexure,  or  ileum,  up  over  the  psoas  muscle,  be- 
side the  main  bloodvessels,  to  the  kidney.  The  ureters  thus  run 
through  the  subperitoneal  connective-tissue  chamber  and  mark  the 
boundary  of  the  fat  containing  tissue  externally,  and  that  without  fat 
internally  (W.  A.  Freund).  They  pass  under  and  behind,  but  not 
into  the  peritoneal  cavity,  and  are  practically  inseparable  from  the 
outside  surface  of  the  peritoneum  behind  the  broad  ligaments,  and 
the  dense  connective  tissue  under  them. 


Vagina. 
.The  vagina  is  attached  posteriorly  to  the  cervix,  the  sacro-uterine 
ligaments,  the  rectum,  and  by  the  recto-vesical  fascia  to  the  levator 
ani  muscles ;  superiorly  to  the  anterior  portion  of  the  cervix,  the  bases 
of  the  broad  ligaments  and  to  the  pubo-uterine  tissues ;  and  anteriorly 
and  inferiorly  by  the  recto-vesical  fascia  to  the  pubes,  and   to  the 


VAGINA. 


29 


levator  vaginae  muscle,  which  passes  around  the  vaginal  introitus  like 
a  sling  or  sphincter  (Fig.  13)  and  mingles  with  the  longitudinal  mus- 
cular fibres  of  the  external  vaginal  coat.  Behind  the  symphysis  on 
either  side  of  the  urethra  the  vaginal  wall  is  drawn  up  behind  the 
posterior  surfaces  of  the  pubes  and  the  pelvic  fascia,  forming,  to  the 
touch,  an  oval  fossa  on  either  side,  which  we  will  call  the  urethral  fossae. 
The  urethra,  passing  as  a  ridge  down  between  these  urethral  fossse 

Fig.  13. 


^ppr 


Manner  of  insertion  of  the  Cervix  Uteri  into  the  Vagina,  showing  the  relation  of  the  Vagina  to 
the  Pelvic  Roof  (Schematic— 3^). 
ppr,  plane  of  the  pelvic  floor  ;  su,  sacro-uterine  ligament ;  Iv,  levator  vaginae  fibres,  passing  up 
to  posterior  surface  of  pubes  ;  pu,  connective-tissue  attachment  of  anterior  vaginal  wall  to  pubo- 
uterine  system  ;  ass,  axis  of  the  superior  strait  of  pelvis  ;  ahc,  division  of  cervix  into  the  infra- 
vaginal  portion  (a),  the  intermediate  (6)  and  the  supra-vaginal  portion  (c)  (after  Schrceder). 

and  under  the  pubic  arch,  leaves  a  depression  or  notch  on  either  side, 
the  urethral  notches,  leading  from  the  arch  back  into  the  fossffi.  (See 
Fig.  14  UN,  and  Fig.  16.)  Farther  back  the  anterior  wall  becomes  flat 
and  forms,  at  the  junction  with  the  lateral  walls,  the  anterior  vaginal 
sulci  or  grooves,  which  lead  from  the  urethral  fossse  back  to  the 
lateral  fornices. 

The  vagina  is  thus  suspended  from  the  pelvic  roof  in  the  subperito- 
neal or  pelvic  connective  tissue  chamber.  It  may  be  likened  to  a  col- 
lapsed cylinder  into  whose  upper  side  the  cervix  is  inserted  at  a  right 
or  acute  angle  with  its  longitudinal  diameter,  and  near  its  upper  ex- 
tremity. Fig.  14  (from  Henle)  shows  the  manner  of  collapse  at  .the 
vaginal  entrance  in  the  cadaver.  In  the  living  subject  the  contraction 
of  the  levator  vaginse  would  tend  to  shorten  both  the  rectal  and  vaginal 
slits,  and  thus  slightly  differ  from  the  figure.  The  posterior  vaginal 
wall  above  the  introitus  is  from  a  half-inch  to  an  inch  and  a  half  above 
the  pelvic  floor  in  the  median  line,  is  applied  to  the  flat  anterior  wall 
by  the  action  of  the  levator  ani  muscles,  the  rectum,  atmospheric 


30      ANATOMY    AXD    PHYSIOLOGY   OP    FEMALE    PELVIC    ORGANS. 


pressure  and  elasticity  of  the  surrounding  tissue.  The  rectum  in  pass- 
ing under  the  vagina  forms  a  broad  longitudinal  ridge  a  little  to  the  left 
of  a  median  position.  On  either  side  of  this  ridge  the  mucous  mem- 
brane of  the  introitus  vaginas  forms  a  notch,  which  may  be  called  the 


Fig  14. 


Horizontal  Section  of  Pelvic  Floor  near  the  Pelvic  outlet  (Henle). 
JJa,  Urethra  ;  Va,  vagina ;  R,  rectum  ;  UN,  urethral  notches ;  RN,  rectal  notches. 

rectal  notches,  the  right  one  of  which  is  deeper  and  broader  than  the 
left  (Figs.  14  and  16).  These  rectal  notches  also  lead  into  posterior 
vaginal  grooves  or  sulci  corresponding  to  those  in  the  anterior  walls. 
The  elevation  or  projection  of  the  lower  end  of  the  posterior  wall  where 
it  is  held  up  by  the  levator  vaginse  and  rectum  forms  the  recto-vaginal 
promontory  of  Prof.  T.  G.  Thomas.  The  vagina  passes  backwards  at  an 
angle  of  from  30  to  45  degrees  with  the  horizon,  according  to  the  ten- 
sion of  the  muscles  and  fascise  about  the  vaginal  entrance  and  uterine 
ligaments.*     In  the  child-bearing  woman  the  posterior  vaginal  wall 

*  A  measurement  of  D.  B.  Hart's  figure  upon  wlijch  he  bases  his  statement  that  the 
vagina  passes  back  at  an  angle  of  60°  with  the  horizon,  will  show  that  the  uterus  and 
vagina  are  both  reduced  J  in  length  and  the  perineum  prolapsed  and  distorted,  either 
by  spirit  hardening  or  other  post-mortem  clianges,  and  cannot  stand  for  the  position  of 
the  parts  in  life.  A  normal  uterus  3  inches  long  placed  with  the  vagina  at  an  angle 
of  60°  would  lift  the  os  two  inciies  from  the  coccyx,  and  project  the  anteverted  fundus 
above  the  pelvic  brim  upon,  instead  of  beliind,  the  symphysis  pubis.  Tiie  difference 
in  the  inclination  of  the  vagina  in  the  living  and  the  dead  would  seem  to  be  caused 
largely  by  the  greater  sagging  of  the  lower  end  of  the  vagina.  The  recto-vaginal  pro- 
montory is  depressed  by  relaxation  of  tissue,  and  the  urethra,  with  its  bed  of  connec- 
tive tissue,  being  unsupported,  comes  down  with  the  anterior  vaginal  wall. 


RELATION  OF  UTERUS  TO  BLADDER.  31 

often  lies  on  the  rectum  or  pelvic  floor,  especially  when  depressed  by 
a  heavy  uterus,  and  partially  unfolded  by  the  examining  finger.  The 
vagina,  by  lining  or  cementing  together  the  pelvic  roof,  also  materially 
adds  to  the  strength  of  the  suspensory  uterine  supports.  The  uterus 
not  unfrequently  receives  some  support  by  resting  upon  a  contracted 
posterior  vaginal  wall,  but  hardly  ever  rests  with  the  whole  weight 
upon  the  pelvic  floor,  unless  it,  or  its  superior  supports,  have  lost  their 
healthy  and  natural  condition  and  relationship. 

Plane  of  the  Pelvic  Roof. 

The  chief  plane  of  the  pelvic  roof  is  thus  described  by  Savage 
(Female  Pelvic  Organs,  3d  ed.  p.  26) :  *'  A  plane  passing  from  the  pos- 
terior surface  of  the  pubis,  about  its  middle  to  the  junction  of  the 
third  and  fourth  sacral  bones — the  sacral  attachments  of  the  utero- 
sacral  muscles,  cutting  the  uterus  at  the  junction  of  the  uterine  body 
and  uterine  cervix,  would  upon  the  whole,  with  trifling  exceptions, 
divide  the  pelvic  cavity  into  peritoneal  and  subperitoneal  cellular  pelvic 
spaces."  Also  (p.  27) :  "  For  the  rest,  as  well  remarked  by  Henle,  the 
relations  of  the  peritoneum  with  the  pelvic  organs  above  the  pelvic 
plane  exactly  agree  with  the  supposition  that  they  were  thrust  up- 
wards against  its  under  surface  in  attaining  their  respective  positions." 
(See  Figs.  1  and  2,  pr  and  prp.)  The  result  of  this  kind  of  support, 
'viz.,  a  suspension  of  the  uterus  near  the  junction  of  the  corpus  and 
cervix,  is  as  if  the  uterine  body  rested  on  a  ball-and-socket  joint,  and 
as  if  the  neck  hung  from  a  support  of  the  same  character.  Being 
joined  at  the  point  of  support  the  cervix  and  body  must  move  together, 
although  always  in  opposite  directions.  The  plane  of  the  pelvic  roof 
holds  this  cervico-uterine  plane  in  place,  but  does  little  to  hold  the 
fundus  and  external  os  in  place.  The  upper  portions  of  the  broad 
and  the  round  ligaments  are  the  only  direct  support  of  the  fundus, 
while  thej)osterior  wall  of  the  vagina  as  applied  by  its  own  elasticity 
or  by  atmospheric  pressure  is  the  only  direct  support  of  the  external 
OS.  But  all  checks  upon  the  fundus  act  as  checks  upon  the  distal  end 
of  the  cervix,  whose  action,  however,  is  modified  by  the  flexibility  or 
rigidity  of  the  uterus  according  to  the  case.  The  relation  of  abdominal 
pressure  to  the  pelvic  roof  is  one  of  the  chief  factors  to  be  considered 
in  the  supports  of  the  fundus,  as  will  be  explained  hereafter. 

Relation  of  Uterus  to  Bladder. 

The  uterus,  which  in  early  life  is  made  up  mostly  of  the  cervix,  and 
lies  upon  the  posterior  wall  of  the  bladder,  retains,  in  adult  life,  its 
original  and  main  supports  at  the  cervix  where  the  peritoneum  is 
reflected.  As  its  body  develops  above  the  cervical  attachment  toward 
the  peritoneal  cavity,  so  as  to  deeply  indent  it  and  receive  a  peritoneal 


32      ANATOMY    AXD    PHYSIOLOGY    OF    FEMALE    PELVIC    ORGA^'S. 


covering  of  its  own,  the  bladder  and  cervix  sink  from  the  pelvic  brim 
down  into  the  pelvic  cavity.  The  fmidus  uteri  becomes  loosely  sus- 
j)ended  in  the  broad 'ligaments,  or  folds  of  the  indented  peritoneum 
on  either  side,  and  is  held  forward  over  the  bladder  by  the  round  or 
spermatic  ligaments.  It  will  thus  be  noticed  that  the  uterus  lies  from 
the  beginning  against  the  bladder,  and  that  the  fundus  is  provided 
with  no  ligament  to  prevent  it  from  resting  upon  the  bladder  until  the 
broad  ligaments  are  i3ut  upon  the  stretch. 

Relation  of  Pelvic  Roof  to  the  Pelvic  Floor. 

As  the  heavy  abdominal  viscera  are  hung  up  in  the  abdominal 
cavity,  and  the  weight  of  the  remainder  is  not  in  a  direct  manner 
borne  by  the  tilted  pelvic  roof,  but  little  other  supj)ort  is  necessary  when 
the  body  of  the  individual  is  in  a  state  of  rest.  But  during  muscular 
exertion  a  jjressure  equal  to  one  or  perhaps  several  hundred  pounds 
is  sometimes  brought  to  bear  upon  it.  Hence  it  is  necessary  that 
there  should  be  a  firm  floor  upon  which  the  organs  may  be  piled,  and 
retained  within  the  pelvic  cavity  until  the  extraordinary  force  ceases 
to  act,  and  the  retractility  of  the  natural  supports  of  the  displaced 
organs  can  draw  tl^m  back  in  position.  Such  a  support  is  the  pelvic 
floor. 

II.  The  Pelvic  Floor. 

The  pelvic  floor  is  made  up  of  the  lower  end  of  the  sacrum,  the 
coccyx,   portions  of  the    ischia,  the  sacro-sciatic  and  coccygeo-anal 

Fig.  15. 


SACPO 


PUBIS. 


MTERNAL 
OBTURATOR 


LARGE  SAC  RC -SCIATIC  LIG. 
Internal  Obturator  Muscle  and  Sacro-sciatic  Ligaments  (Tarnicr  and  Chantreuil). 

ligaments,  portions  of  the  gluteal,  internal  obturator  (Fig.  15),  pyram- 
idal, levatores  ani  and  coccygeal  muscles  with  their  fascia?,  the  recto- 


THE   PELVIC    FLOOR. 


33 


vesical,  levator,  obturator,  etc.,  and  some  looser  connective  tissue.  The 
upper  surface  formed  anteriorly  of  the  levatores  ani,  has  a  sort  of 
resemblance  to  the  shape  of  the  bottom  of  a  boat.  (See  Figs.  7,  18,  19.) 
Its  centre  in  the  meridian  line  is  formed  by  the  lower  end  of  the 
sacrum,  the  coccyx,  the  coccygeo-anal  ligament,  and  the  meeting  of 
the  levatores  ani  muscles  behind  the  rectum.  This  is  the  portion 
shown  on  the  median  sections  (Figs.  1,  2,  3).  The  rectum  is  seen  to 
pass  down  over  it  and  then  turn  suddenly  back,  at  the  rectal  promon- 
tory, to  reach  the  anus.  Such  a  section  can,  however,  show  but  little 
of  the  pelvic  floor  and  give  but  a  very  imperfect  illustration  of  its 


urethra- 


gluteub 


coccyx 


Pelvic  Floor  Outlet  and  Vaginal  Entrance. 

All  tissue  beneath  it  removed  except  rectum  and  anal  sphincters. 

Rectum  is  seen  passing  forward  under  the  pelvic  floor  and  over  its  edge  into  the  pelvic  cavity 
p.f.  e  corresponds  to  pfe  of  Fig.  1. 

u.  n.,  urethral  notch;  v.,  vagina;  t.  v.,  levator  vaginae;  e.  I.  a.,  edge  levator  ani;  r.  n.,  rectal 
notch;  r.  p.,  rectal  promontory;  r.,  rectum;  p.f.  e.,  pelvic  floor  edge. 

complete  relationship.  From  this  rectal  promontory,  as  a  median  sec- 
tion (Fig,  1,  pfe)  makes  its  lower  border  appear,  the  edges  of  the 
levator  ani  muscles  pass  up  to  the  rami  of  the  pubes  like  the  sides  of 
the  letter  V,  forming  the  lower  edge  of  the  pelvic  floor,  as  represented 
in  Fig.  16  (edge  levator  ani),  leaving  an  inverted  triangular  insuffi- 
ciency or  outlet.  The.  rectal  promontory  or  anterior  edge  of  the  leva- 
tores ani  in  the  median  line  thus  represents  the  bottom  or  angle  of 

the  V. 

3 


34      ANATOMY  AND   PHYSIOLOGY   OF   FEMALE   PELVIC   ORGANS. 


Relationship  of  the  Muscles  of  the  Pelvic  Floor  and  Interxjosed  Tissues. 

Fig.  17  gives  a  view  of  the  attachment  of  the  levator  ani  and  the 
levator  vaginae  behind  the  piibes.  Fig.  18  shows  the  levator  vaginae 
of  one  side  passing  between  the  vagina  and  rectum  as  a  small  bundle, 
a  continuation  of  the  levator  ani  proper,  which  in  turn  passes  to  the 
lateral  and  posterior  surfaces  of  the  rectum,  to  the  median  line  behind 
the  rectum,  and  to  the  ano-coccygeal  ligament  and  coccyx.  It  also 
shows  the  coccygeus  muscle,  which  is  the  continuation  posteriorly  of 
the  levator  ani,  spreading  from  a  small  attachment  to  the  spine  of  the 
ischium  like  a  half-expanded  fan,  towards  the  internal  lateral  edge 
of  the  coccyx.     Fig.  19  portrays  the  superior  aspect  of  these  muscles, 

Fic.  17 


Pubic  Attachments  of  the  Levatores  Ani  et  Vaginae  Muscles  (Savage).    View  from  behind. 
S,  symphysis  pubis;  U,  urethra;  V,  vagina;  1,  pubic  attachment  of  bladder;  2,  pubic  attach- 
ment of  levator  vaginae;  3,  line  of  attachment  of  levator  ani;  4,  pudic  vein;  5,  urethral-pubal 
venous  plexus;  6,  posterior  face  of  perineal  septum;  7,  levator  vaginae. 

constituting  the  main  upper  surface  of  the  pelvic  floor.  The  attach- 
ments anteriorly  to  the  posterior  surface  of  the  pubic  bones,  laterally 
to  the  white  line,  or  dividing  of  the  pelvic  fascia  into  the  obdurator 
and  recto-vesical,  and  posteriorly  to  the  ischial  spines,  are  plainly  in- 
dicated. The  median  line  attachments,  also  shown,  must  be  consid- 
ered as  a  little  more  depressed  below  the  level  of  the  lateral  attach- 
ments than  would  appear  from  a  hasty  glance  at  the  figure.  To  get 
the  plane  of  this  muscular  part  of  the  pelvic  floor  which  closes  the 
bony  pelvic  outlet,  and  the  part  displaced  or  retracted  in  labor,  com- 
pare with  Fig.  7  (l). 


ABDOMINAL   PRESSURE. 


35 


Above  the  levator  plane  lies  the  subperitoneal  connective  tissue 
chamber,  below  it  the  ischio-rectal  fossa  or  vault  (cavum  ischio-rectale) 
filled  with  cellular  tissue,  affording,  above  and  below,  elastic  support 
for  the  constantly  varying  plane  of  the  pelvic  floor,  and  guarding 
against  any  interference  with,  or  from,  surrounding  organs.  The 
ischio-rectal  fossa  stretches  between  the  rectum  and  ischium  (Fig.  7)  : 
its  apex  runs  up  along  the  levator  ani  muscle  to  the  white  line  or 


Fig  is 


Muscles  of  the  Pelvic  Floor  (Savage.) 
1,  2,  levator  ani;  3,  coccygeus;  4,  white  line  (arcus  tendineus,  Luschka);  5,  coccyx;  6,  median 
line  raphiS;  U,  bladder;  F,  vagina;  J2,  rectum;  P,  pubic  symphysis. 

obturator  attachment ;  its  base  is  the  skin  and  superficial  fascia  from 
the  lower  edge  of  the  perineal  fascia  (transversus  perinei)  in  front,  to 
the  lower  edge  of  the  gluteus  maximus  behind. 

The  pyriformis  muscles,  whose  chief  clinical  importance  lies  in  the 
fact  that  more  important  structures  lie  around  and  upon  them,  and 
that  when  contracted  their  bellies  may  be  mistaken  by  the  examining 
finger  for  more  important  structures,  are  situated  farther  back,  behind 
the  coccygeus  muscle  and  smaller  sacro-sciatic  ligament  (Figs.  18  and 
19),  and  pass  from  the  anterior  surface  of  the  sacrum  about  half  an 
inch  on  either  side  of  the  median  line,  through  the  sacro-sciatic  fora- 
men, to  the  major  trochanter. 

Abdominal  Pressure. 
The  abdominal  pressure,  when  the  abdominal  walls  are  relaxed  or 
not  strongly  contracted,  is  considerably  modified  by  gravity  and  by 


36      ANATOMY   AND    PHYSIOLOGY   OF   FEMALE   PELVIC   ORGANS. 


the  elasticity  of  the  pelvic  tissues.  During  muscular  activity  it  is 
partly  reflected  around  the  hollow  of  the  sacrum  in  the  direction  of 
the  pelvic  axis  curve,  and  partly  exerted  directly  downward  behind  the 
symphysis  pubis.     In  Fig.  20,  the  arrows  indicate  in  a  general  way  the 


Horizontal  Section  of  Pelvis,  giving  a  view  of  the  Muscles  of  the  Pelvic  Floor  from  above. 


B,  neck  of  bladder;  V,  vagina;  E,  rectum;  P,  pubic  symphysis;  C,  coccyx;  S,  sacrum;  A.  acetabu- 
lum; 1,  ant.  vesical  lig.;  2, 3,  levator  ani ;  4,  white  line;  5,  coccygeus  muscle;  6,  smaller  sacro-sciatic 
lig.;  7,  pyriformis  muscle;  8,  obturator  muscle. 

directions  of  abdominal  pressure.  The  resultant  of  these  two  forces 
(the  direct  and  the  reflected  pressure)  which  meet  at  the  pelvic  floor 
outlet  from  almost  opposite  directions,  will  be  weak  as  compared  with 
the  original  one,  and  will  be  through  the  V-shaped  outlet  (Fig.  20). 
The  reflected  pressure  coming  around  the  hollow  of  the  sacrum,  but 
for  the  pelvic  floor  projection,  or  rectal  promontory  in  front  of  the 
coccyx,  would  be  expended  upon  the  anus,  as  indicated  by  the  dotted 
arrow.  But  when  this  anterior  edge  of  the  pelvic  floor  is  firm,  it  not 
only  overlaps  the  anal  region,  but  still  farther  reflects  the  pressure 
towards  the  apex  of  the  pubic  arch  to  meet  the  direct  pressure  higher 
up  as  indicated  by  the  heavy  arroAvs.  With  the  forefinger  in  the 
vagina,  curved  so  as  to  extend  from  the  symphysis  back  toward  the 


ABDOMINAL   PRESSURE. 


37 


coccyx,  and  the  thumb  externally  over  the  ano-coccygeal  region,  while 
the  patient*  stands  and  bears  down  forcibh^,  we  may  detect  the  two 
forces,  one  depressing  the  coccyx  and  coccygeo-anal  ligament,  and  the 
other  the  urethral  region. 

This  play  of  abdominal  pressure  on  the  muscles  of  the  pelvic  floor 
and  perineum  (which  are  voluntary  muscles,  and  contract  during  any 
general  muscular  exertion)  develops  and  strengthens  them  in  propor- 
tion to  the  activity  and  development  of  the  whole  muscular  system, 
and  partly  explains  the  presence  of  varying  degrees  of  firmness  of  the 

Fig.  20. 


Illustration  of  the  Action  of  Abdominal  Pressure  upon  the  Uterus  {^). 
The  clotted  arrow  indicates  the  direction  of  the  strain  upon  the  pelvic  floor.    The  crossed 
arrows  show  the  meeting  of  the  direct  pressure  and  that  reflected  by  the  pelvic  floor. 

parts  in  different  persons  of  the  same  age  at  their  first  confinement. 
The  control  of  the  pelvic  floor  by  the  will  also  explains  how  during 
excessive  straining  early  in  labor,  before  these  muscles  are  stretched, 
the  parturient  is  liable  to  firmly  contract  them  and  induce  a  state 
of  artificial  rigidity  exceedingly  difficult  for  her  to  overcome;  and 
also  explains  how  the  pelvic  floor  may  temporarily  support  with 
impunity,  a  pressure  many  times  greater  than  that  of  labor,  pressure 

*  A  nullipara  with  uninjured  pelvic  viscera  must,  if  possible,  be  selected  for  this 
experiment. 


38      ANATOMY   AXD   PHYSIOLOGY   OF    FEMALE   PELVIC   ORGANS. 


which  without  such  vokmtary  contraction  would  overstretch  all  the 
ligaments  of  the  pelvic  organs  and,  if  frequently  repeated,  lead  to 
displacements*     (See  Fig.  21.) 

Requirements  for  the  Closure,  of  the  Pelvic  Floor  Insufficiency. 

We  are  now  prepared  to  understand  the  problem  which  is  left  to  be 
solved,  viz.,  to  close  up  this  V-shaped  opening  without  interfering  with 
the  evacuations  of  the  viscera  or  the  progress  of  parturition.  The 
abdominal  pressure  during  muscular  relaxation  being  but  small  in 
quantity  at  this  point,  and  during  muscular  exertion  almost  entirely 
counteracted  by  the  contraction  of  the  pelvic  floor,  all  that  is  called 

Fig.  21. 


Voluntary  Contraction  of  the  Pelvic  Floor  during  Straining  and  Lifting  {%). 
Uterus  is  carried  down  in  the  direction  of  the  pelvic  axis  while  the  pelvic  floor  edge  and 
perineum  are  drawn  toward  the  pubis  so  as  to  close  the  pelvic  outlet.    Compare  with  Fig.  1. 

for  to  close  the  V-shaped  insufficiency  is  a  mass  of  tissue  firm  enough 
to  support  the  walls  of  the  outlets  of  the  bladder,  vagina  and  rectum, 
and  elastic  enough  to  allow  of  great  distension  without  losing  its 
power  of  retractility.  This  we  have  in  the  perineum,  the  classical 
object  of  wonder  to  the  ignorant,  and  of  confusion  to  the  wise,  yet 
whose  only  wonderful  quality  is  its  simplicity  of  structure  and 
function. 


*  See  "Control  of  the  Pelvic  Floor  Muscles  by  the  Will,"  p.  106. 


PERINEUM. 


39 


III.  Perineum. 
The  perineum  or  pelvic  portico  is  an  entirely  supplementary  support 
as  far  as  the  uterus  is  concerned.     Constructed  on  a  muscular  frame- 

FlG.  22. 


lv~ 


urethra 


ps 


Perineal  Muscular  System  (Schematic). 
Iv,  levator  vaginse ;  cc,  constrictor  cunni ;  ps,  perineal  septum ;  /,  fourchette. 

work  below  the  pelvic  floor,  it  guards  the  pelvic  floor  insufficiency, 

Fig.  23. 


Dissection  of  the  Muscles  of  the  Perineum  and  Pelvic  Floor  (Savage). 
A,  anus;  B,  bulb  of  vagina;  C,  coccyx ;  L,  larger  sacro-sciatic  lig.;  P,  perineal  body;  U,  urethra  ; 
V,  vagina;  G,  vulvo-vaginal  gland;  1,  clitoris;  2,  its  suspensory  lig.;  3,  crura  clitoridis;  4,  erector 
clitorldis  muscle;  5,  constrictor  cunni;  7,  transversus  perinei;  8,  sphincter  ani,  ext.;  9, 10,  levator 
ani;  11,  coccygeus;  12,  obturator  ext. 


40  "anatomy  and  physiology  of  female  pelvic  organs. 


and  supports  the  projecting  visceral  outlets.  During  great  abdominal 
pressure,  labor,  etc.,  the  pelvic  floor  is  brought  in  contact  with  the 
perineum  and  temporarily  strengthened.  This  temporary  union, 
having  been  so  often  observed  by  gynecologists  and  obstetricians,  has 
led  them  to  describe  the  pelvic  floor  and  perineum  as  an  anatomical 
and  physiological  unit,  and  has  thus  given  rise  to  infinite  confusion. 
Fig.  22  shows  its  muscular  framework  in  a  schematic  way.  It  will 
be  seen  that  the  levator  vaginae,  or  vaginal  sphincter,  comes  down 


Pig.  24. 


Perineal  Fascia  laid  open  and  part  of  the  muscles  cut  out.  Inferior  surface  of  pelvic  floor 
(levator  fascia),  forming  the  upper  boundary  of  the  ischio-rectal  fossa.  The  fossa  is  shown  with 
fatty  connective  tissue  removed. 

a,  gluteus  maximus;  L,  larger  sacro-sciatic  lig.;  T,  tuber  ischii;  A,  anus;  C,  clitoris;  M,  urethral 
meatus;  6,  sphincter  ani,  ext.;  d  e,  transversus  perinei  and  constrictor  cunni ;  g,  erector  clitoridis; 
V,  vagina;/,  muscular  fibres  of  perineal  septum,  the  remainder  scraped  away;  I,  bulb  partially 
cut  away  to  show  its  sheath. 

from  the  internal  or  posterior  surface  of  the  pubis  to  be  attached  to 
the  upper  posterior  part  of  the  raphe  in  the  median  line  at  the  vaginal 
entrance.  It  may  be  said  to  be  hung  (or  fitted)  in  the  pelvic  floor  in- 
sufficiency. The  constrictor  cunni  or  vulval  sphincter  (bulbo  caver- 
nosus)  comes  down  from  the  external  or  anterior  surface  of  the  pubis 
to  be  attached  to  the  raphe  in  the  vulva  under  the  fourchette.  Thus 
the  upper  part  of  the  so-called  triangle  of  the  perineal  body  is  pro- 


PEEINETJM. 


41 


vided  for.  The  transversiis  perinei  comes  from  the  tuberosity  of  the 
ischium  to  be  attached  to  the  same  raphe  between  the  sphincter  ani 
and  the  fourchette.  The  sphincter  ani,  attached  posteriorly  by  a  liga- 
ment (foreshortened  in  the  illustration)  to  the  coccyx,  passes  forward 
to  the  same  tendinous  raphe.  Fig.  23  shows  a  superficial  dissection 
of  the  parts.  The  perineal  muscles  are  strengthened  by  the  three 
layers  of  the  perineal  fascia  which  cover  all  but  the  sphincter  ani,  and 
pass  laterally  to  the  pubic  rami.  Fig.  24  shows  them  laid  open,  in  dis- 
section.    Between  the  two  posterior  layers  of  these  fasciae,  which  are 

Fig.  25. 


Pelvic  Floor  and  Perineal  Fasciae. 
rv,  recto-vesical  fascia,  internal  layer  of  pelvic  floor  fascia ;  I,  levator  fascia,  external  layer  of 
pelvic  floor  fascia  (see  Fig.  31) ;  ps,  perineal  septum,  or  triangular  ligaments,  the  internal  layers 
of  perineal  fascia ;  el,  external  layer  of  perineal  fascia.  (In  the  median  line  the  external  or 
vulval  layer  of  the  perineal  fascia  is  close  to  the  perineal  body  as  represented,  but  on  either  side 
it  is  a  little  more  voluminous.)  (For  more  exact  relationship  of  the  fascite  to  the  perineal  body, 
see  Fig.  31.) 

sometimes  called  the  anterior  and  posterior  layers  of  the  triangular 
ligament,  lies  the  constrictor  urethrse,  constituting  with  these  two 
layers  of  fascia  the  perineal  septum  of  Savage  (Fig.  22).  The  lower 
portion  or  edge  of  the  constrictor  urethrse  on  either  side,  which  is 
situated  just  behind  the  transversus  perinei,  is  often  called  the  trans- 
versus  perinei  internus.  Fig.  25  shows  the  pelvic  floor  and  perineal 
fascise  in  median  sagittal  section. 

The  sphincter  ani  is  between  the  ischio-rectal  fossae  or  vaults,  but 


42      AXATOMY   AXD    PHYSIOLOGY    OF    FEMALE    PELVIC    OE,G-AXS. 

entirely  below  the  pehdc  floor.  The  permeum  is  connected  with  the 
pelvic  roof  by  the  vaginal  attachments  of  the  levatores  vaginse  and  the 
perineal  fasciae,  and  to  the  pelvic  floor  by  the  ano-coccygeal  ligament, 
and  by  the  fascial  coverings  and  pubic  attachments  of  the  levatores 
ani  et  vaginae.  The  perineum  is  separated  from  the  pehdc  floor  by  the 
ischio-rectal  vault  (Fig.  7)  and  the  backward  curve  of  the  rectum  from 
the  rectal  promontory,  or  pelvic  floor  edge,  to  the  anus  (Figs.  1  and  2). 
The  pelvic  floor  lies  as  a  whole  within  or  above  the  external  conjugate 
or  pubo-coccygeal  line,  while  the  perineum  lies  below  or  external,  al- 
though their  points  of  meeting  lie  anteriorly  above  and  posteriorly  at  or 
a  trifle  below  it.  Hence  I  would  call  the  projection  of  these  parts  below 
the  external  conjugate,  not  the  pelvic  floor  projection  (Schroeder, Foster, 
Hart  and  Barbour,  etc.),  but  the  perineal  area  or  projection.  This  pro- 
jection varies  with  the  age,  weight,  muscular  vigor,  and  the  position  of 
the  woman,  as  well  as  with  the  condition  of  the  parts,  as  resulting  from 
pregnancy,  child-bearing,  inj  ury ,  or  local  disease.  My  conclusions,  based 
wpon  examinations  and  measurements,  would  make  Foster's  estimate 
of  one  inch  (2.5  centimetres)  a  liberal  average  for  healthy  women,  the 
healthy  extremes  being  about  half  an  inch  and  an  inch  and  a  half. 

Perineal  Body. 
The  convergence  of  the  perineal  muscles  and  fascia  about  the  median 
line  raphe  forms  what  has  been  called  the  perineal  body.  The  rectum, 
cur^dng  backwards  between  the  perineum  and  pelvic  floor,  gives  the 
body  the  shape  of  a  muscular  band  a  little  thicker  anteriorly  than  poste- 
riorly, and  about  an  inch  and  a  half  long,  stretched  across  the  pelvic 
floor  outlet  or  insufficiency.  Its  inner  surface  is  covered  by  the  rectum, 
its  outer  by  the  skin,  and  its  upper  by  the  skin  and  mucous  membrane 
of  the  vulva  and  introitus  vaginae.  Quite  a  quantity  of  cellular  tissue, 
continuous  with  the  ischio-rectal  vaults,  is  found  under  the  rectal  sur- 
face, and  a  smaller  quantity  under  the  skin  at  the  posterior  commissure. 

Measurements  of  the  Perineal  Body. 
The  median  line  raphe  is  about  one-eighth  of  an  inch  (30  mm.)  in 
width.  A  median  section  through  it  shows  what  has  been  called  the 
perineal  triangle  (Fig.  1).  Fig.  26  shows,  by  means  of  dotted  lines, 
the  shape  of  the  raphe  in  the  triangle,  natural  size.  I  have  measured 
the  perineal  triangle  in  five  young  virgins ;  ten  married  women,  be- 
tween twenty  and  forty  years  old,  who  had  either  not  yet  conceived,  or 
had  miscarried  under  three  months;  and  two  married  women  of  fifty 
and  fifty-four  years  respectively.  The  accompanying  table  represents 
the  average  measurements  of  the  sides  of  the  triangles  in  these  cases  : 


5  virgins. 

10  married 

2  senile 

multiparas. 

muUiparte. 

Vulvo-vaginal  side,     . 

4 

1 

2  and    f 

Cutaneous  side,  . 

.              .        l| 

u 

Uand  U 

Eectal  side, 

•       If 

H 

1|  and  1^ 

CHAEACTERISTICS    OF   THE    PERINEAL   BODY. 


43 


The  first  measurements  of  the  senile  cases  belonged  to  a  small  thin 
sterile  woman  fifty -four  years  old ;  the  other  to  a  fleshy  one  about 
fifty,  who  claimed  to  have  had  miscarriages.  Figs.  26,  27,  and  28 
represent  the  perineal  triangle  as  constructed  from  these  figures. 

Characteristics  of  the  Perineal  Body. 

The  character  of  the  perineal  bod}^  as  a  support  is  derived  from 
the  perineal  muscles  and  the  double  layer  of  internal  perineal  fasciae, 
the  perineal  septum;  and  its  shape  varies  with  their  tension  and  firm- 
ness.    In  many  virgins  of  firm  muscular  fibre  the  fourchette  is  pulled 


Fig.  26. 


Fig.  27. 


•    c^     '    f 


cl\\   CI 


Perineal  TriaBgles  of  Virgin  (life  size). 
Fig.  28. 


Married  Xulliper. 
Fig.  29. 


Old  Woman,  50-54  years, 
rectal  side  ;  ct,  connective  tissue  ; 


CV 


Old  Maid  before  Menopause.* 
fi,  hymen;  /,  fourchette;  pc,  posterior  commissure;  a  a, 


sphincter  ani.    Dotted  lines  indicate  size  and  shape  of  tendinous  raphe. 

up  so  as  to  form  an  acute  angle  (Fig.  26),  while  in  married  women 
the  relaxation  of  the  constrictor  cunni  usually  drops  the  fourchette  so 
as  to  form  a  right  or  obtuse  angle  (Fig.  27).  Contraction  of  the  levator 
vaginae  draws  the  hymen,  which  seems  to  be  a  continuation,  or  per- 
forated edge,  of  the  posterior  triangular  ligament  or  j^erineal  septum, 
into  the  pelvic  floor  outlet,  so  as  to  stretch  the  posterior  commissure 
over  the  edge  of  the  tendinous  raphe,  and  round  off  or  flatten  the 
angle  (Fig.  29).  Great  relaxation  of  the  whole  perineal  structure 
produces  a  sagging  of  the  tendinous  raphe  as  indicated  in  Fig.  30. 
Fig.  31  illustrates  the  relative  position?  of  the  muscles  and  fascise  in 
the  perineal  body. 


*  This  form  also  occurs  in  the  young  who  have  irritable  or  tight  sphincters. 


44      ANATOMY   AND   PHYSIOLOaY    OF    FEMALE    PELVIC    ORGANS. 


Fig. 


Action  of  the  Perineum  as  a  Siipi^ort. 
The  resisting  power  of  the  perineum  varies  with  the  character  and 
direction  of  the  force  acting  upon  it.     If  a  destructive  pressure  bears 

upon  it  so  as  to  put  all  its  muscles 
upon  the  stretch  to  an  equal  degree? 
the  median  raph6  will  be  the  first 
portion  to  part  asunder.  When  any 
muscle  or  pair  of  muscles  are  sub- 
jected to  a  greater  strain  than  the 
others,  such  muscles  must  usually 
give  way  before  the  raphe.  Calling 
the  sphincter  ani  the  ajDex  of  the 
perineal  triangle  or  pyramid,  its  base 
is  in  relation  with  the  urethra  in 
front.  Its  greatest  efficiency  as  a  sup- 
port is  to  a  force  or  weight  bearing  or  resting  upon  the  base  or  vulvo- 
vaginal side,  for  the  resisting  powers  of  the  levator  vaginae,  constrictor 
cunni,  and,  later,  the  transversus  perinei  are  enlisted,  and  the  fascise 


Shape  relaxed  Perineal  Triangle  {\). 


,xr 


Fig.  31. 


*  Relations  of  Muscles  and  Fascia  to  Perineal  Body  {\). 

cc,  constrictor  cunni  or  vulval  sphincter;  tp,  transversus  perinei;  tp,  rectal  promontory  or 
pelvic  floor  edge  ;  Iv,  levator  vagince  or  vaginal  sphincter;  ps,  perineal  septum  ;  //,  levator  fascia 
and  posterior  layer  of  perineal  septum ;  el,  external  layer  of  perineal  fascia ;  rv,  recto-vesical  or 
the  internal  or  visceral  layer  of  the  pelvic  fascia ;  is,  internal  sphincter  ani ;  a  a,  sphincter  ani. 

are  stretched  in  a  direction  almost  parallel  to  their  surfaces  (Fig.  31). 
Pressure  from  the  apex  or  rectal  side  meets  the  resistance  of  the 
sphincter  ani,  transversi  perinei,  and  lower  or  posterior  edge  of  the 
perineal  fascia. 

The  ordinary  reflected  abdominal  pressure  is  deflected  from  the 
rectal  promontory  of  the  pelvic  floor,  so  that  the  perineal  body  re- 
ceives the  final  resultant  near  its  base,  or  stronger  portion  (Fig.  20). 
If  the  pressure,  however,  be  through  a  fluid  or  semi- fluid  medium  in 
the  rectum,  it  will  be  exerted  around  the  pelvic  floor  edge  or  rectal 
promontory,  and  have  only  the  resistance  of  the  sphincter  ani  to 
overcome.  If  it  be  exerted  through  a  large  solid  body  of  conical 
shape  in  the  vagina,  as  in  labor,  the  levator  vaginns  will  be  pushed 
downwards  and  backwards  with  the  levator  ani,  and  the  perineal 


ACTION    OF    THE    PERINEUM    AS    A   SUPPORT. 


45 


body  doubled  or  folded  upon  itself  at  the  posterior  commissure,  or  a 
point  just  external  to  the  relaxing  constrictor  cunni  (Fig.  32),  and  a 
folded  or  double  tendon  will  be  opposed  to  the  descending  occiput  to 

Fig.  32. 


Folding  of  the  Perineal  Body  in  Normal  Labor  when  Dilated  by  means  of  the  Bag  of  Waters  or 

Caput  Succedaneum  {%). 
The  dots  on  the  perineal  body  indicate  connective  tissue  containing  fat. 
p.  c,  post,  commissure ;  e.  c.  c,  edge  constrictor  cunni  or  vulvar  sphincter  ;  e.  I.  v.,  edge  levator 
vaginae  or  vaginal  sphincter;  a.,  anus;  e.l.a.,  edge  levator  ani ;  e.l.c,  edge  levator  coccygei ; 
e.  c,  edge  coccygeus  ;  s,  s.  I.,  smaller  sacro-sciatic  ligament. 

direct  it  up  through  the  dilating  vulva.  The  pressure  upon  the  peri- 
neal body  will  be  from  base  to  apex.  The  internal  perineal  fascia 
(perineal  septum)  will  be  stretched  in  a  direction  parallel  to  its  sur- 
faces, and  will  suffer  but  moderate  attenuation,  or  loss  of  resisting 
power.  In  cases  of  rigidity  of  the  perineal  tissues  in  labor,  or  in 
absence  of  a  suitable  dilating  cone  or  wedge,  such  as  the  pouch  of 
membranes  or  a  large  caput  succedaneum,  the  levator  ani  will  still  be 
pressed  back  by  the  head,  but  the  levator  vaginae  and  constrictor 
cunni,  not  being  thus  pushed  back,  will  be  pressed  forward  before 
the  head,  away  from  the  levator  ani,  and  in  a  direction  at  right  angles 
to  their  plane  of  contraction,  and  will  swing  out  or  bulge  at  their 
perineal  or  movable  attachments  in  proportion  to  the  stretching  of 


46       ANATOMY    AND    PHYSIOLOaY    OF    FEMALE    PELVIC   ORGANS. 

the  lower  weaker  portions  of  the  perineum  (Fig.  33).  The  anterior 
edge  or  base  of  the  perineal  body  will  thus  be  left  to  be  pulled  back 
by  the  stretched  and  depressed  lower  portions.  Already  torn  from 
its  connective  tissue  relations  with  the  levator  ani  and  rectum,  the 


Fig.  33. 


Flattening  of  the  Perineal  Body  in  Labor  due  to  rigidity  of  the  outlet  or  improperly  directed 

force  (%). 

p.  c,  post,  commissure;  e.  c.  c,  edge  constrictor  cunni;  e.  I.  v.,  edge  levator  vaginse  (Hymen) ; 
a.,  anus;  e.  I.  a.,  edge  levator  ani;  e.  I.  c,  edge  levator  coccygei;  e.  c,  edge  coccygeus;  e.  s.  s.  I.,  edge 
smaller  sacro-sciatic  ligament. 

perineum  is  drawn  and  flattened  into  a  thin  nicmbrane  with  the  line  of 
advance  (or  pelvic  axis)  passing  through  it,  somewhere  near  its  centre. 

As  injuries  of  the  perineum  and  pelvic  floor  are  largely  due  to  the 
pressure  of  the  head  in  labor,  an  understanding  of  the  various  changes 
occurring  in  the  perineum  during  labor  is  necessary  to  a  full  under- 
standing of  the  difl'erent  lesions  of  the  parts  and  their  restoration  to 
normal  relationship. 

The  Rectum. 

The  female  rectum  is  an  organ  of  great  interest  to  the  gynecologist, 
sinee  for  almost  the  whole  eight  inches  of  its  length  it  is  in  intimate 
relation  with  the  generative  organs.  Just  inside  of  the  external  sphinc- 


THE    RECTUM. 


47 


ter  ani,  the  circular  muscular  fibres  of  its  middle  coat  form  a  supple- 
mentary or  internal  or  second  sphincter  (Fig.  34).  From  the  anus, 
the  rectum  passes  forward  directly  behind  the  perineal  body  (Fig.  31), 
making  a  very  small  angle  with  the  horizon  until  it  reaches  the  poste- 
rior vaginal  wall  and  recto-vaginal  angle  of  the  perineal  triangle,  an- 
teriorly, and  the  pelvic  floor  edge  or  rectal  promontory,  posteriorly. 


Fig.  34. 


Muscular  Fibres  of  the  Rectum. 
Rectum  of  a  male  subject,  cut  open  longitudinally,  and  the  mucous  membrane  dissected  off  so 
as  to  show  the  circular  muscular  fibres.  DD'  correspond  to  same  letters  in  Fig.  35,  and  indicate 
the  aggregation  of  fibres  constituting  the  anterior  and  posterior  segments  of  the  superior  Detru- 
sor Fsecium  (Third  Sphincter).  S,  is  the  inferior  Detrusor  Feecium  (Internal  Sphincter).  A,  Anus ; 
t  and  *  correspond  to  same  marks  on  Fig.  35.  This  drawing  shows  the  muscular  fibres  passing 
from  the  anterior  to  the  posterior  segment  of  the  superior  Detrusor,  by  the  action  of  which  they 
may  be  approximated  to  each  other.— (After  Chadwick.) 

It  then  takes  a  sudden  turn  up  around  the  pelvic  floor  edge,  in  through 
the  pelvic  floor  outlet  or  insufficiency,  and,  bearing  a  little  to  the  left, 
passes  backwards  again  at  an  acute  angle  with  the  horizon  (Fig.  1) 
along  the  coccygeo-sacral  groove.  At  this  lower  turn  or  promontory 
of  the  rectum,  the  levator  ani,  when  contracting,  draws  the  bowel  for- 
ward against  the  anterior  vaginal  wall  and  practically  constitutes  a 


48      ANATOMY   AND   PHYSIOLOGY   OF   FEMALE   PELVIC   OEGANS. 


third  sphincter.  After  passing  under  and  a  little  to  the  left  of  the 
cervix  the  rectum  curves  up  behind  the  uterus  between  the  sacro- 
uterine ligaments  or  folds.  Its  lateral  deviation  corresponds  with  the 
twisting  of  the  uterus  upon  its  axis  so  as  to  bring  the  left  side  a  little 
in  front  of  the  right.     The  rectum,  receiving  its  peritoneal  covering 


Fig.  85. 


Distended  Rectum. 
Rectum  from  a  male  subject  tied  below  at  the  anus  and  inflated.  DD'  are  the  anterior  and  pos- 
terior segmentsof  the  superior  Detrusor  Fsecium  (Third  Sphincter).  Uis  the  a?npo«t?e  )-cctafe,  t  and 
*  correspond  to  same  marks  in  Fig.  34.  This  drawing  shows  the  sinuosities  of  the  rectum  main- 
tained by  the  action  of  the  longitudinal  fibres  at  the  points  where  the  circular  fibres  are  collected 
in  bundles,  notably  the  two  lower  ones.— (After  Chadwick.) 

over  the  anterior  and  lateral  surfaces  at  the  Douglas  cul-de-sac  and 
sacro-uterine  folds  proceeds  upward  to  join  the  sigmoid  flexure  of  the 
colon  near  the  left  sacro-iliac  synchondrosis  in  the  false  pelvis. 

It  is  normally  empty  and  lies  on  its  bed  as  an  irregular  or  flattened 
cylindrical  mass  of  movable  tissue,  partly  filling  the  pelvic  floor  out- 
let so  as  to  press  the  posterior  vaginal  wall  against  the  anterior  (Fig. 
16).  It  is  attached  by  loose  connective  tissue  to  the  vaginal  wall  as 
far  back  as  the  cul-de-sac  of  Douglas  or  recto-uterine  peritoneal  pouch 


THE    EECTUM.  49 

and  as  far  back  as  the  coccyx  is  held  in  position  by  the  action  of  the 
levator  ani.  Where  the  rectum  curves  up  behind  the  cervix,  and  just 
under  or  behind  the  sacro-uterine  folds,  an  augmentation  of  the  cir- 
cular muscular  fibres  on  its  anterior  surface  produces  a  slight  semi- 
circular band  or  constriction,  which,  when  rigid,  may  be  mistaken 
during  "  digital "  examination  of  the  rectum  for  the  semicircular  out- 
line of  the  sacro-uterine  folds.  Fig.  35  gives  the  apj)earance  of  this 
constriction  (D)  in  the  inflated  male  rectum,  removed  from  the  body. 
In  the  healthy  relaxed  female  rectum,  in  the  living  subject,  these  con- 
strictions, lying  in  the  rectal  folds,  are  not  always  easily  felt.  Just 
above  this  anterior  constriction  is  another  on  the  posterior  side  (D').^ 
Fig.  33  represents  the  course  of  the  muscular  fibres  through  these 
parts.  When  both  bands  are  contracted  they  do  not  completely  close 
up  the  rectum,  but  are  apt  to  be  approximated  in  such  a  manner  as  to 
overlap  and  close  the  passage,  and  constitute,  in  an  imperfect  manner, 
a  fourth  sphincter  which  may  give  the  examining  finger  some  trouble 
in  finding  its  wa}^  past  them.  According  to  Chad  wick,  during  the 
rhythmic  contractions  of  the  rectum  these  constrictions  or  half  sphinc- 
ters contract  separately  and  consecutively  so  as  to  aid  in  expelling  the 
fseces.  As  will  be  seen  in  Fig.  34,  these  constrictions  are  merely  con- 
tinuations and  exaggerations  of  smaller  constrictions  above,  all  of 
which  act  to  hold  the  fseces  firmly  while  passing  them  on,  and  are 
admirably  adapted  to  prevent  over-distension  of  the  gut  by  agglom- 
erated excreta.  In  the  pouch,  between  the  rectum  and  uterus,  are 
often  found  intestinal  folds  and  peritoneal  fluid. 

It  will  be  readily  perceived  how,  although  normally  empty,  the 
rectum,  at  the  bottom  of  the  subperitoneal  chamber  and  in  direct 
relationship  with  the  uterus,  the  sacro-uterine  peritoneal  folds  and  sub- 
jacent tissue,  is  apt,  during  even  moderate  distension  by  gases  and  de- 
scending fseces,  to  press  injuriously  upon  the  pelvic  tissues  that  are  in 
a  state  of  inflammation ;  and  also  why  it  so  frequently  becomes  the 
avenue  of  escape  of  pus  from  pelvic  abscesses.  At  the  left  sacro-iliac 
synchondrosis,  the  sigmoid  flexure  of  the  colon,  or  fifth  sphincter  of 
the  bowel,  marks  the  region  above  which  fseces  are  normally  lodged. 
When  this  portion  is  over-distended  the  fecal  tumor  may  so  press 
upon  the  uterus  and  its  surroundings  as  to  weaken  its  supports,  dis- 
turb its  circulation  and  interfere  with  its  nervous  supply.  The  pas- 
sage of  fecal  matter  from  the  csecal  valve  (sixth  sphincter)  through  the 
colon  to  the  rectum  is  normally  a  slow  one,  and  in  females  of  seden- 
tary or  indolent  habits  is  often  accomplished  with  great  delay  and 
difficulty.  The  result  is  a  continuous  state  of  fulness  of  the  lower 
terminus  and  sometimes  of  almost  the  whole  extent  of  the  colon,  with 
its  baneful  influence.     The  late  Dr.  J.  S.  Jewell,t  of  this  city,  has  re- 

*  Transactions  Am.  Gynecological  Soc,  vol.  ii.,  p.  43. 
t  Transactions  Chicago  Medical  Society,  1886. 
4 


50      ANATOMY   AND   PHYSIOLOaY   OF   FEMALE   PELVIC   OEGANS. 

moved,  inside  of  thirty  hours  by  means  of  bland  enemata  and  mas- 
sage, two  gallons  of  fecal  matter  from  the  colon,  over  and  above  the 
quantity  introduced  into  the  bowels.  The  almost  immediate  relief 
from  cold  feet,  indigestion,  ofFensiveness  of  the  cutaneous  secretions, 
muddiness  of  complexion,  nervous  depression,  etc.,  and  the  astonish- 
ing fact  that  he  has  records  of  over  five  hundred  cases  of  a  similar 
kind,  would  make  it  appear  that  disorders  of  the  colon  and  rectum 
are  more  important  factors  in  the  etiology  of  uterine  diseases,  and 
the  accompanying  symptoms,  than  has  been  generally  suspected. 

The  Bladder. 

The  bladder  in  the  female  is  largely  supplied  by  the  same  vessels 
and  nerves  as  are  the  generative  organs.  Connected  with  the  vaginal 
wall  below  and  the  uterus  behind,  it  is  more  exposed  to  injury  than 

Fig.  .S6. 


Relation  of  the  Ureters  to  the  Bladder  and  Uterus,  (J)— (Luschka). 


in  the  male,  and  at  the  same  time  is  more  easily  accessible  for  surgical 
treatment.  When  empty  it  is  drawn  together  in  a  flattened,  flabby 
mass,  lying  between  the  anterior  vaginal  wall,  symphysis  pubis  and 
corpus  uteri  (Fig.  1),  and  projects  into  the  para-vesical  pouches.  As 
it  becomes  filled  with  urine  it  tends  to  press  the  fundus  upward  and 


BLOODVESSELS.  51 

backward  toward  the  pelvic  axis  (Fig.  3).  In  so  doing  it  also  presses 
back  the  internal  os  a  little,  so  that  while  the  external  os  is  turned 
forward  by  the  rising  fundus,  it  remains  in  nearly  the  same  location. 
If  the  corpus  uteri  be  heavy,  or  the  fundus  deprived  of  its  usual 
mobility,  the  filling  bladder  becomes  indented  by  it,  and  rises  on  both 
sides  of  the  uterus,  or  if  the  fundus  be  drawn  to  one  side  rises  on  the 
opposite  side,  and  thus  forms  either  one  or  two  fluctuating  tumors  later- 
ally situated.  When  greatly  distended  the  bladder  rises  over  the 
symphysis  pubis,  pushes  up  the  small  intestine  and  lower  edge  of  the 
peritoneum  and  impinges  against  the  abdominal  walls. 

The  trigone  (Fig.  36)  lies  over  the  anterior  vaginal  wall.  Its  base, 
the  inter-uretric  ligament,  is  from  an  inch  to  an  inch  and  a  half  in  front 
of  the  cervix,  and  may  be  felt  as  a  ridge  between  their  vesical  open- 
ings. Its  apex  is  from  an  inch  to  an  inch  and  a  half  beyond  the 
meatus  urinarius  at  the  opening  of  the  urethra  into  the  bladder. 

Bloodvessels. 

The  pelvic  connective  tissue  is  traversed  by  vessels  which  run 
tortuous  courses,  and  anastomose  freely,  and  therefore  accommo- 
date themselves  easily  to  the  great  stretching  and  displacement  to 
which  such  tissue  is  sometimes  physiologically  subjected.  The  largest 
bloodvessels  of  the  female  genital  organs  are  situated  posteriorly  on 
either  side  (Figs.  8  and  9)  and  in  the  broad  ligaments.  The  internal 
iliac  artery  comes  down  from  the  pelvic  brim  and  divides  above  the 
upper  border  of  the  greater  sacro-sciatic  foramen  behind  the  sacral 
pouches.  The  branches  found  in  the  pelvis  from  the  anterior  trunk 
are :  the  superior  vesical  passing  under  the  peritoneum  and,  after 
giving  off  the  middle  vesical  to  the  bladder,  continuing  as  the  oblit- 
erated hypogastric  artery ;  the  uterine,  passing  into  the  broad  ligament 
above  the  spine  of  the  ischium,  giving  off  the  vaginal  artery  near  the 
cervix,  and  sometimes  the  middle  hemorrhoidal;  the  obturator,  pass- 
ing over  the  ischial  spine  forward  to  its  point  of  exit  from  the  pelvis 
at  the  upper  anterior  portion  of  the  muscle  of  the  same  name,  and 
giving  off  branches  anteriorly  to  the  pelvic  brim  and  pubis ;  the  middle 
hemorrhoidal,  passing  along  the  upper  surface  of  the  pelvic  floor  in- 
wards and  forwards  to  the  rectum — often  giving  off,  near  its  origin  the 
inferior  vesical ;  the  internal  pudic,  passing  out  between  the  coccygeus 
and  the  pyriformis  muscles  ;  and  the  sciatic,  passing  out  between  the 
same  muscles,  but  just  behind  and  internal  to  the  pudic,  between  the 
first  and  second  sacral  nerves.  The  main  branch  of  the  posterior 
trunk  is  the  gluteal  which  leaves  the  pelvis  just  behind  or  above  the 
edge  of  the  pyriformis  muscle  and  first  sacral  nerve.  The  ilio-lumbar 
branch,  given  off  at  the  pelvic  brim,  passes  back  to  the  lumbar  region 
and  iliac  fossa  anastomosing  with  the  last  lumbar  artery,  the  glu- 


52      AXATOMY   A^-D    PHYSIOLOGY    OF    FEMALE    PELVIC   OEGAXS. 


teal,  circumflex  iliac,  external  circumflex  and  epigastric  arteries. — 
(Gray). 

The  rectum  does  not  lie  against  any  of  the  large  arteries,  below  the 
upper  edges  of  the  sacro-uterine  folds ;  above  them  it  passes  over  the 
left  iliac.  It  has  no  large  arteries  upon  its  anterior  surface  except  the 
hemorrhoidal  which  can  be  easily  felt  by  the  finger,  and  avoided  in 
operations.     Behind  the  rectum  high  up  lies  the  sacra-media. 

The  ovarian  or  spermatic  arteries,  branches  of  the  abdominal  aorta, 
do  not  enter  the  true  pelvis,  but  pass  over  the  brim  between  the  folds 
of  the  broad  ligaments  to  the  ovaries  and  upper  portion  of  the 

Fig.  37. 


Arterif 


Distribution  of  tlie  Ovarian,  Uterine  and  Vaginal  Arteries— (Hyrtl). 


uterus.  The  uterine  artery  passes  into  the  base  of  the  broad  liga- 
ment, not  far  from  the  spine  of  the  ischium,  across  to  the  side  of  the 
uterus  near  the  internal  os,  and  then  up  between  the  folds  of  the 
peritoneum  to  anastomose  freely  with  the  ovarian  artery  (Fig.  37). 
The  internal  pudic  passes  out  of  the  subperitoneal  connective  tissue 
chamber  and  the  pelvis  through  the  greater  sacro-sciatic  foramen, 
across  the  ischial  spine  externally,  enters  the  ischio-rectal  vault 
through  the  lesser  sacro-sciatic  foramen,  passes  across  the  inner  sur- 
face of  the  tuberosity  and  ramus  of  the  ischium,  up  along  the  pubic 
ramus  to  the  perineum  and  vulva.  The  ol;)turator  arteries  frequently 
arise  from  the  posterior  branch  of  the  internal  iliacs.     The  veins  of  the 


LYMPHATICS.  53 

pelvis  follow  the  arteries,  and  are  particularly  alDundant  iDetween  the 
layers  of  the  broad  'ligament  external  to  the  arteries,  and  in  the  pos- 
terior wall  of  the  vagina.  They  are  unprovided  with  valves  and  apt 
to  bleed  excessively  when  cut  or  ruptured. 

Nerves. 

The  spinal  nervous  supply  of  the  pelvis  is  derived  chiefly  from  the 
sacral  plexus,  the  fourth  and  fifth  sacral,  and  the  coccygeal  nerves. 
The  sacral  plexus  lies  upon  the  anterior  surface  of  the  pyriformis 
muscle.  The  pudic  is  given  off  from  the  sacral  plexus,  and  with  its 
hemorrhoidal  and  three  perineal  branches  affords  the  chief  nervous 
suppty  to  the  perineum,  vulva  and  vagina.  The  small  sciatic  supplies 
the  integument  of  the  perineum.  The  fourth  and  fifth  sacral,  coccy- 
geal and  hemorrhoidal  branches  supply  the  pelvic  floor.  The  hypo- 
gastric plexuses  and  lower  ganglia  of  the  sympathetic  nervous  system 
supply  the  internal  pelvic  organs,  and  are  particularly  liberal  in  their 
allowance  to  the  uterus  and  its  appendages.  The  uterus  itself  depends 
for  its  spinal  nervous  supply  upon  the  filaments  that  accompany  the 
sympathetic  nerves,  and  is,  therefore,  in  the  unimpregnated  state, 
almost  devoid  of  ordinary  sensation,  and  can  be  subjected  to  great 
irritation  and  even  affected  with  organic  disease  without  giving  ap- 
parent inconvenience  to  the  system.  It  seems  to  r(;quire  a  participa- 
tion of  the  peritoneal  or  fibro-cellular  surroundings  of  the  uterus,  or  a 
sufiicient  change  in  its  submucous  and  muscular  substance  to  decidedly 
interfere  with  the  functions  of  these  nerves,  or  else  an  abnormally 
debilitated  state  of  the  nervous  tissue,  for  the  production  of  any  appre- 
ciable resentment  on  the  part  of  the  general  nervous  system.  How- 
ever, let  this  vast  accumulation  of  nervous  elements  finally  become 
involved  in  pathological  changes,  and  the  lack  of  sensibility  will  not 
prevent  the  most  profound,  far-reaching,  mysterious  and  often  disas- 
trous reflex  efi'ects.  The  abundance  of  the  spinal  nerve  supply  to  the 
perineum,  pelvic  floor  and  vulva,  explains  how  uterine  and  ovarian 
irritation,  congestion  and  inflammation,  instead  of  being  felt  at  their 
seats,  may  be  symptomatized  by  a  reflected  irritability  of  the  sphinc- 
ters, by  pruritis  vulvee  et  vaginae,  vaginismus,  coxalgia,  etc. 

Lymphatics. 

Lymphatic  glands  are  chiefly  found  about  the  cervix  uteri,  in  the 
upper  portion  of  the  pelvic  connective  tissue  chamber,  behind  the 
broad  ligaments  and  on  the  sacrum  at  either  side  of  the  rectum,  be- 
tween the  large  bloodvessels,  and  along  the  obturator  artery.  Lym- 
phatic vessels  are  abundant  everywhere  in  the  pelvis.  Those  about 
the  cervix  communicate  directly  with  the  connective  tissue  chamber 
and  lower  portion  of  the  broad  ligament.     Hence  infection  from  the 


54       ANATOMY   AND    PHYSIOLOGY    OF    FEMALE    PELVIC   ORGANS, 

cervix  is  apt  to  lead  to  pelvic  abscess,  while  infection  from  the  uterine 
body  may  give  rise  to  extensive  peritoneal  inflammation  without  sup- 
puration. 

For  the  structural  anatomy  of  the  pelvic  viscera  and  external  genitals,  the  student 
is  referred  to  the  text  books  upon  anatomy  and  histology.  Space  does  not  here  permit 
a  i-epetition  of  these  things,  which  are,  or  should  be,  a  part  of  the  mental  equipment 
of  every  graduate  in  medicine. 


CHAPTER    II. 

EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS. 

FoKTUNATELY  for  suffering  woman,  we  may  arrive  at  demonstrative 
knowledge  of  the  locality  of  her  several  pelvic  organs  and  of  the 
nature  and  extent  of  the  diseases  which  affect  them,  and  consequently 
treat  them  with  the  certainty  which  a  positive  diagnosis  always  in- 
sures. The  evident  advantages  of  a  physical  diagnosis  will  render  it 
quite  unnecessary  for  me  to  use  any  argument  in  favor  of  it,  or  to  in- 
duce medical  men  to  resort  to  it.  A  physical  examination,  however, 
of  the  genital  apparatus  of  females,  is  quite  a  different  matter  from  a 
physical  examination  of  the  chest,  eye,  or  ear,  or  any  other  organ  of 
the  body  ;  and  hence  the  necessity  of  approaching  and  conducting  it 
under  conditions  rendered  imperative  on  account  of  the  circumstances 
connected  with  it.  The  education  and  natural  sense  of  modesty,  so  ap- 
propriate to  female  character,  and  which  always  commands  the  respect 
of  gentlemen,  make  such  examinations  disgusting  and  disagreeable  above 
almost  all  others  demanded  by  the  necessities  of  woman's  circum- 
stances. AVith  a  view  to  this  fact,  it  is  our  duty,  by  our  conduct 
toward  our  patient,  and  the  management  of  the  examination,  to  divest 
it  as  nearly  as  possible  of  every  disagreeable  feature.  Medical  men 
generally,  I  think,  are,  as  they  should  be,  actuated  by  the  above  consid- 
erations, and  I  fear  that  they  are  often  so  influenced  by  their  ov/n  sense 
of  delicacy  as  too  frequently  to  abstain  from  the  enforcement  of  essen- 
tial investigations.  This  is  an  error  we  should  always  bear  in  mind, 
and,  I  think,  we  shall  less  frequently  regret  a  thorough,  although 
somewhat  indelicate  examination  when  dictated  by  an  honest  and 
intelligent  conviction  of  its  necessity,  than  a  neglect  of  such  exam- 
ination from  too  great  a  deference  to  a  sense  of  shame.  We  should 
not,  in  important  cases,  take  things  for  granted. 

Our  bearing  to  a  female  patient  should  be  deferential,  candid,  and 
modest.  She  should  be  convinced  by  our  demeanor  that  everything 
we  do  and  say  is  strictly  necessary  and  relevant  to  her  case,  and  has 
its  foundation  in  our  solicitude  for  her  welfare.  Nothing,  therefore, 
should  be  said  or  done  but  what  is  called  for  and  obviously  proper. 
This  sort  of  treatment  from  her  medical  adviser  will  always  command 
the  confidence  and  earnest  co-operation  of  an  intelligent  female  pa- 
tient. There  should  be  a  full  and  explicit  understanding,  when  pos- 
sible, between  the  physician  and  the  patient,  as  to  the  necessity  of  a 
physical  examination,  in  what  it  consists,  and  how  it  is  to  be  conducted. 
The  good  sense  of  the  practitioner  will  enable  him  to  judge  whether 


56 


EXAMINATION   OP   THE    FEMALE    PELVIC    ORGANS. 


he  should  commit  the  detail  of  explanation  to  the  husband,  or  some 
other  appropriate  second  party,  or  whether  he  impart  it  directly  to  the 
patient ;  all  the  circumstances  of  the  case  will  enable  him  to  determine 
this  matter  without  much  difficulty.  After  the  preliminaries  are  dis- 
posed of  I  would  insist  upon  conducting  the  examination  without 
exposure.  It  is  needless  in  ordinary  uterine  examinations,  and  should 
be  permitted  only  when  the  disease  is  upon  the  external  parts.  One 
position  and  kind  of  jDreparation,  so  far  as  the  patient  is  concerned, 
will  suffice  for  most  cases,  whether  we  wish  to  make  a  manual  or  an 
instrumental  examination.  There  is  no  necessity  for  the  patient  to 
unclothe  herself. 

Position  of  Patient  for  Examination. 

In  the  ordinary  work  of  an  office  I  think  there  is  nothing  more  con- 
venient than  Wilson's  chair.     It  can  be  made  to  assume  so  many  forms 


Fig  38. 


I  Cuicago. 

Operating  Chair. 

that  it  can  be  used  as  a  chair  or  table  either,  and  is  easily  moved  into 
any  position  in  relation  to  the  light. 

For  many  purposes,  however,  a  table  will  afford  us  more  satisfaction. 
It  is  very  much  to  be  preferred  in  surgical  operations. 

While  the  gynecological  table  represented  in  Fig.  39  is  very  conve- 
nient for  an  office,  an  ordinary  table  such  as  can  be  found  in  any 
dwelling  can  be  made  to  answer  every  purpose. 

There  are  three  positions  of  which  we  may  avail  ourselves  in  making 
examinations  or  performing  operations:  the  dorsal,  the latcro-abdomi- 
nal,  or  Sims's  position,  and  the  knee-chest  position. 

In  the  ordinary  dorsal  position  the  patient  is  placed  on  her  back 
with  the  breech  very  near  the  end  of  the  table  or  chair,  the  knees 


POSITION    OF    PATIENT    FOR   EXAMIXATIOJST. 


57 


flexed  and  the  thighs  drawn  up  close  to  the  abdomen,  the  feet  resting 
by  the  side  of  the  nates  or  in  the  stirrups,  and  the  shoulders  elevated 
upon  j)illows.     In  this  position  the  abdominal  walls  are  relaxed  and 


Fig.  39. 


Byford's  Operating  Table. 


brought  near  the  pelvic  organs  (Fig.  44),  and  both  hands  may  be  used 
with  great  freedom  in  exploring  them. 

It  is,  in  fact,  indispensable  to  a  perfect  bimanual  examination,  and 
is  very  convenient  for  the  use  of  the  sound,  and  almost  every  form  of 


Fig.  40. 


Position  for  Sims's  Speculum. 

speculum.     Even  Sims's  speculum  can  be  made  to  do  effectual  service 
in  this  position. 

For  many  minor  operations  and  uterine  applications  it  is  a  very 
convenient  position.  This  was  a  favorite  position  with  the  late  Pro- 
fessor Simon.  When  the  hips  and  shoulders  are  greatly  elevated,  the 
knees  extended,  and  thighs  forcibly  flexed  upon  the  abdomen,  this  is 
called  Simon's  position,  and  is  not  inferior  to  any  other  for  examination 
or  surgical  operations  on  the  vagina  and  uterus. 


58  EXAMIXATIOX    OF   THE    FEMALE    PELVIC   ORGANS. 

Sims's  position  consists  in  placing  the  patient  on  her  left  side,  with 
the  left  arm  under  and  behind  the  body,  and  both  knees  drawn  up  close 
to  the  abdomen ;  the  right,  flexed  to  a  greater  degree,  and  overlying  the 
left,  rests  on  the  table  in  front  (Fig.  40).  The  abdomen  becomes  some- 
what dependent  and  draws  the  pelvic  organs  away  from  the  external 
outlets.  When  the  perineum  is  drawn  back  the  vagina  is  distended 
by  atmospheric  pressure,  and  the  vaginal  wall  and  uterus  brought  into 
view. 

The  knee-chest  position  is  also  Sims's  position,  and  produces  the 
same  effect  in  dilating  the  vagina  obtained  by  the  other,  only  perhaps 
in  an  exaggerated  degree  (Fig.  92). 

Peraission  of  the  Pelvic  Organs. 

Percussion  gives  us  but  little  information  concerning  the  healthy 
pelvic  organs,  but  may  be  valuable  in  determining  the  absence  of 
such  enlargements  and  misplacements  as  are  known  to  bring  them 
within  the  field  of  such  an  examination. 

Intestinal  resonance  usually  exists  over  the  pubes,  but  during  great 
distension  of  the  bladder  is  replaced  by  dulness,  extending  some- 
times almost  or  quite  to  the  umbilicus.  In  case  such  dulness  be  due 
to  a  distended  bladder,  firm  pressure  will  produce  a  feeling  of  tension 
or  pain  on  the  part  of  the  patient  at  the  neck  of  the  bladder,  or  a 
sensible  depression  of  the  anterior  vaginal  wall,  or  fluctuation,  upon 
a  finger  placed  in  the  vagina. 

An  accumulation  of  feeces  high  up  in  the  rectum  often  produces  a 
decided  dulness  on  percussion  over  the  left  iliac  region. 

Palpation  of  the  Pelvic  Roof — Digital  Examination  through  the  Vagina. 

The  mode  of  examining  the  pelvis  with  the  fingers  is  of  the  utmost 
importance.  After  oiling  the  fore  and  middle  fingers  (Fig.  44)  the 
index  should  be  very  gently  introduced,  and  the  examination  con- 
ducted as  far  as  possible  with  it ;  then  the  two  may  be  introduced 
and  nearly  all  of  the  cavity  of  the  pelvis  explored.  The  index  finger 
will  not  reach  as  far  as  the  two  together,  but  it  is  more  delicate  and 
intelligent  in  touch,  and  is  less  hampered  by  vaginal  resistance. 

The  rectum,  as  it  curves  over  the  pelvic  floor  edge  into  the  pelvic 
cavity,  lies  immediately  under  and  to  the  right^  of  the  finger.  When 
partly  filled  with  freces  it  is  felt  as  a  soft  round  ridge  upon  the  floor 
and  posterior  wall  of  the  pelvis,  when  empty  as  a  loose  or  easily  dis- 
placed fibrous  cord  or  bundle  of  cords;  or  it  may  be  almost  unrecog- 
nizable through  the  resistant  vaginal  walls  and  surrounding  connec- 
tive tissue.     Sometimes  one  or  more  hard  fecal  lumps  just  below  or 

*  Left  side  of  the  patient. 


THE    CERVIX   UTEEI    OF   THE    CHILD-BEARING   WOMAN.  59 

behind  the  cervix  uteri,  in  an  otherwise  empty  rectum,  will  indicate 
its  course ;  at  other  times  a  fecal  mass  as  large  as  an  egg  will  project 
from  the  pelvic  floor  in  front  of  the  cervix ;  or  a  large  accumulation 
may  be  felt,  tumor  like,  behind  and  over  the  uterus. 

Inflammation,  induration,  or  stricture  of  the  rectum  will  be  re- 
vealed by  sensitiveness,  hardness,  or  a  point  of  contraction.  Indeed, 
this  easy  and  painless  method  of  examining  the  rectum,  and  elimi- 
nating as  far  as  possible,  rectal  disease  from  our  diagnoses  in  gyneco- 
logical cases,  should  receive  careful  attention  and  study. 

Next  we  should  turn  our  finger  forward,  pass  it  up  behind  the 
symphysis  pubis,  and  along  the  front  wall  of  the  vagina,  and  as  defi- 
nitely as  practicable  ascertain  the  condition  of  the  bladder.  The 
examination  is  more  complete  if  the  fingers  of  the  left  hand  are 
pressed  into  the  pelvis  just  above  the  symphysis  pubis,  and  approxi- 
mated to  the  finger  behind  the  pubis.  Any  foreign  body,  morbid 
deposit,  displacement  of  the  bladder  from  its  median  position,  any 
thickening,  inflammation  or  hypersesthesia  of  its  walls,  etc.,  can  thus 
be  detected. 

Characteristics  of  the  Cervix  Uteri. 

After  palpating  the  rectum  and  bladder  we  should,  as  a  starting- 
point  to  a  farther  exploration  of  the  pelvis,  locate  the  neck  of  the 
uterus. 

-  In  passing  through  the  vaginal  canal,  the  uneducated  finger  is  im- 
pressed with  a  soft  intestinal  sensation,  and  can  distinguish  nothing 
but  loose  folds,  that  are  dissipated  and  lost  in  the  surrounding  soft- 
ness by  the  slightest  pressure,  until  it  comes  to  the  neck  of  the  uterus, 
which  has  consistence  enough  to  retain  its  shape  under  considerable 
pressure.  If  pushed  upward,  backward,  or  downward,  it  retains  the 
same  characteristics.  The  finger  can  be  carried  up  beside,  before,  or 
behind,  and  around  it  in  every  direction  except  above.  This,  being 
unlike  anything  else  in  the  vagina,  will  be  easily  recognized. 

The  Virgin  Cervix. 

The  virgin  cervix  uteri  is  almost  cylindrical  in  shape,  slightly 
compressed  from  before  backward,  and  not  far  from  three-quarters  of 
an  inch  in  diameter  in  every  direction.  It  projects  half  to  three- 
quarters  of  an  inch  into  the  vagina,  a  little  deeper  behind  than  in 
front  (Fig.  41).  It  points  toward  the  coccyx,  and  at  the  projecting  or 
free  end  is  apparently  cut  nearly  square  off,  so  as  to  present  almost  a 
flat  surface,  with  a  dimple  in  the  centre  corresponding  to  the  os  uteri. 

The  Cervix  Uteri  of  the  Child- Bearing  Woman. 

The  cervix  uteri  of  the  child-bearing  woman  is  about  an  inch  wide, 
or  often  a  little  more,  and  from  half  to  three-quarters  of  an  inch  in 


60 


EXAMINATION   OF   THE   FEMALE   PELVIC   ORGANS. 


its  antero-posterior  diameter.     Instead  of  being  truncated  it  feels  as 
if  formed  of  two  projections  at  its  inferior  extremity,  the  anterior  and 


Fig.  41. 


Virgin  Uterus  and  Vagina. 


posterior  labia  separated  by  a  distinct  fissure,  which  runs  transversely 
and  represents  the  os  (Fig.  42), 


The  Senile  Cervix. 

The  OS  uteri  in  advanced  age  does  not  project  into  the  vagina,  and 
often  feels  more  like  a  pit  at  its  termination  (Fig.  43).  There  is  often  a 
cord  or  frsenum-like  projection  in  the  vaginal  walls,  which  is  planted 
into  the  external  surface  of  the  anterior  and  posterior  lips  of  the 
mouth  of  the  uterus,  and  thus  extends  backward  and  forward  to  be 
lost  in  the  anterior  and  posterior  median  lines  of  the  walls  of  the 
vagina.  This  fraenum  becomes  more  apparent,  if  not  more  developed, 
as  women  advance  in  age ;  but  I  have  known  it  to  be  so  prominent 
as  to  be  mistaken  for  disease,  even  in  the  middle  aged.  In  one  case 
an  intelligent  practitioner  thought  it  an  evidence  of  the  injurious 
effect  of  strong  caustics. 

The  consistence  of  the  virgin  and  parous  cervix  uteri  is  tlie  same. 
To  the  sense  of  touch  it  gives  the  idea  (which  is  a  correct  one)  of 


LOCATIO:S    OF    THE    CEEVIX   UTEEI. 


61 


deep  fibrous  tissue,  almost  as  hard  as  cartilage,  covered  over  thickly 
with  areolar  tissue.   Dr.  Bennett  compares  it  to  the  feel  of  the  cartilage 


Fig.  42. 


Fig.  43. 


Uterus  of  the  Child-bearing  Woman. 


Senile  Uterus  and  Vagina. 


of  the  lower  end  of  the  nose.     It  seems  to  me  not  quite  so  dense^ 
although  nearly  -so. 

Location  of  the  Cervix  Uteri. 

The  location  of  the  cervix  varies  with  the  position  of  the  patient. 
When  she  stands  erect  its  anterior  wall  is  at  or  a  little  back  of  the 
axis  of  the  superior  strait,  and  hence  about  two  and  a  half  inches,  or 
a  little  farther,  from  the  inferior  pubic  ligament.  When  she  assumes 
the  dorsal  position  the  lower  end  of  the  cervix  is,  on  account  of  the 
altered  abdominal  pressure,  from  a  quarter  to  a  half  inch  nearer  to 
the  vulva.  In  the  Sims's  position  the  cervix  is  draAvn  farther  away 
with  the  receding  abdominal  viscera. 

If,  in  the  dorsal  position,  the  index  finger  be  introduced  along  the 
anterior  vaginal  wall  until  the  middle  of  the  third  phalanx  just 
touches,  or  is  a  little  beyond,  the  inferior  pubic  ligament,  the  anterior 
wall  of  the  cervix  (Fig.  44)  will  be  touched.  By  raising  the  finger 
well  up  at  one  side  of  the  urethra  the  exact  place  of  impingement 


62 


EXAMINATION   OF   THE   FEMALE   PELVIC   ORGANS. 


against  the  ligament  can  be  felt,  and  the  distance  measured.  Passed 
on  under  the  cervix  the  finger  end  will  have  the  os  upon  it,  and  the 
rectum  immediately  under  it. 

The  distance  between  the  os  and  the  coccyx,  after  pushing  aside 
the  rectum,  should  be  about  equal  to  double  the  thickness  of  the 
finger,  i.e.,  the  finger  should  occupy  half  of  the  space.  In  child- 
bearing  women  the  os  is  usually  down  a  little  nearer  to  the  coccyx,  in 
old  women  up  a  little  farther  from  it. 

On  either  side  of  the  cervix  the  finger  should  pass  nearly  an  equal 
distance  outward  before  encountering  the  ischial  bones ;  or  if  the  sur- 
rounding tissue  be  firm,  should  encounter  only  elastic  resistance  on 
either  side.     When  much  lateral  displacement  is  present,  the  finger- 


FlG.  44. 


Digital  Examination  m  the  Dors>al  Position  —Touching  the  Cervix  (J^) 


tip  beside  the  lower  end  of  the  cervix,  finds  the  pelvic  wall  so  near  as 
to  leave  space  for  but  little  lateral  motion  on  one  side ;  while  on  the 
opposite  side  it  may  move  about  freely,  and  reaches  bony  resistance 
only  after  being  pressed  two  or  three  times  as  far  from  the  cervix  as 
was  possible  on  the  side  of  the  displacement.  A  slight  amount  of 
lateral  displacement  may  be  more  easily  estimated  by  laying  the 
finger  end  on  the  coccyx,  and  then  raising  it  up  until  it  touches  or 
glides  by  the  cervix.  With  the  finger  tip  against  the  cervix,  and  the 
finger  touching  the  inferior  pubic  arch,  first  in  one  urethral  notch, 
and  then  in  the  other,  the  distance  from  the  notch  to  the  cervix  is 
less  on  the  side  to  which  the  latter  is  displaced. 


PALPATIO^'^    OF   THE    DISPLACED    UTEEUS.  63 

Corpus  Uteri. 

When  the  uterus  is  normal  in  size,  shape  and  position  the  finger  in 
the  vagina  may  be  pushed  high  up  in  the  fornices  without  encounter- 
ing any  check  except  the  elastic  counter-pressure  of  the  vaginal  walls 
and  surrounding  connective  tissue.  The  hard  body  of  the  uterus, 
when  the  bladder  is  empty,  may  be  felt  for  a  short  distance  along  the 
anterior  vaginal  walls,  gradually  receding  forwards  and  upwards 
beyond  reach.  Any  considerable  quantity  of  fluid  in  the  bladder 
should  lift  the  uterine  body  entirely  out  of  reach  of  the  finger  in  the 
vagina  (see  Fig.  3),  and  give  a  sensation  of  semi-elastic  or  characterless 
resistance. 

Palpation  of  the  Displaced  Uterus. 

If  the  fundus  be  displaced  towards  the  symphysis  the  uterus  may 
be  felt  as  a  smooth  pear-shaped  body,  three  inches  long,  lying  flat 
over,  or  down  upon  the  anterior  wall  of  the  vagina  with  the  os,  at  the 
smaller  end,  pointing  backwards.*  If  the  fundus  be  displaced  back- 
wards the  same  pear-shaped  body  may  be  felt  over  the  posterior  fornix 
vaginae,  lying  with  its  larger  end  against  or  near  the  sacrum,  and  the 
smaller  end  turned  forward,  so  that  the  os  looks  toward  the  perineum 
or  the  pubis.  An  elevation  or  concavity  of  the  anterior  fornix  is 
caused  by  a  backward  displacement  of  the  fundus,  and  is  in  propor- 
tion to  the  displacements. 

The  resistance  of  the  connective  tissue  at  the  bases  of  the  broad 
ligaments  prevents  palpation  of  the  body  of  the  normally  placed 
uterus  through  the  lateral  fornices.  When,  however,  the  fundus  is 
displaced  laterally,  the  os  is  turned  to  the  opposite  side,  and  thus  sec- 
ondarily displaced,  and  the  finger  can  feel  the  lateral  uterine  wall  on 
the  side  of  the  displacement  to  be  continuous,  almost  in  a  straight 
line,  with  the  side  wall  of  the  cervix.  Pressing  high  up  in  the  anterior 
fornix,  on  either  side  of  the  median  line,  it  loses  the  corpus  uteri  on 
one  side,  but  can  trace  it  for  some  distance  toward  the  lateral  pelvic 
wall  on  the  other.  The  lateral  fornix  having  a  definite  relation  to 
the  side  of  the  cervix,  must  be  shallower  and  wider  than  its  opposite 
on  the  side  towards  which  the  fundus  (or  from  which  the  cervix)  is 
displaced. 

When  only  the  cervix  is  displaced  laterally,  the  os  is  felt  turned 
toward  the  side  of  displacement  so  as  to  be  entirely  to  one  side  of  the 
rectum  and  coccyx,  and  the  body  to  extend  toward  the  median  line, 
sustaining  about  the  same  relation  to  the  direction  of  the  pelvic^axis  as 
in  displacement  of  the  fundus  to  the  opposite  side,  but  it  will  reach 

*  B.  S.  Schnltze  calls  attention  to  the  fact  that  the  uterus  is  larger  during  life  than 
after  death  owing  to  the  amount  of  blood  its  vessels  contain.  During  the  ante-menstrual 
congestion  it  is  still  larger. 


64  EXAMIXATIOX    OF    THE    FEMALE    PELVIC    ORGANS. 

only  a  little  be3''ond  its  normal  median  position.  The  fornix  is  also 
higher  and  narrower  on  the  side  of  the  cervical  displacement — unless 
altered  by  a  growth  or  appreciable  deposit — but  the  disparity  of  the 
lateral  fornices  is  greater  in  width  but  less  in  height  than  that  accom- 
panying primary  fundal  displacement. 

In  extreme  lateral  displacement  of  either  end  of  the  uterus,  the  other 
end  while  turned  in  the  opposite  direction  is  drawn  to,  or  over,  the 
median  line,  so  as  to  be  mainly  in  the  same  side  of  the  pelvis. 

In  co-existent  primary  displacements  of  the  fundus  to  one  side  and 
the  cervix  to  the  opposite,  both  are  nearly  equidistant  from  their 
median  positions,  but  the  direction  of  the  long  axis  of  the  bod}'-  of  the 
uterus  will  be  felt  to  be  more  transverse  than  the  amount  of  primary 
displacement  of  the  cervix  or  fundus  alone  would  produce.  The  long 
axis  of  the  body  points  toward  the  iliac  fossa  rather  than  merely  to 
one  side  of  the  pelvic  axis.  The  fornix  on  the  side  of  the  cervical  dis- 
placement will  be  very  much  higher  and  narrower  than  its  opposite. 

Lateral  displacement  of  the  whole  uterus  may  be  recognized  by  the 
nearness  of  the  cervix  to  one  lateral  pelvic  wall,  or  by  its  position  en- 
tirely to  one  side  of  the  rectum  and  cocc3^x,  accompanied  by  a  nearly 
normal  direction  of  the  uterine  axis  or  lateral  walls,  as  determined  by 
passing  the  finger-tip  up  into  and  in  front  of  the  lateral  fornices.  The 
fornix  on  the  side  of  the  displacement  will  be  very  much  narrower, 
but  of  almost  the  same  height  as  its  opposite. 

While  examining  for  lateral  displacements,  when  the  fundus  lies 
back  of  the  pelvic  axis,  we  of  course  palpate  its  posterior  surface  and 
lateral  edges  through  the  posterior  and  lateral  fornices  (see  Fig.  47). 
The  spaces  between  the  sides  of  the  fundus  and  the  pelvic  walls  are 
narrow  and  easily  measured  by  the  finger  pressed  well  back  on  either 
side ;  while  the  direction  of  the  long  axis  of  the  uterus,  and  the  amount 
of  displacement  of  the  os,  are  easily  recognized  by  passing  the  finger 
straight  back  under  the  pubic  arch  along  the  anterior  vaginal  wall  to, 
and  under,  the  cervix.  The  coccyx  under  the  finger  maj^  be  used  as 
a  guide  to  the  median  line. 


Palpation  of  the  Pregnant  Uterus. 

The  pregnant  uterus  assumes,  even  during  the  first  three  or  four 
months,  qualities  that  otherwise  belong  to  pathological  states.  The 
cervix  feels  soft  and  oedematous  about  the  external  os,  is  down  nearer 
the  coccyx,  and  a  little  farther  away  from  the  inferior  pubic  liga- 
ment. The  body  is  felt  to  recede  less  rapidly  upward  from  the  anterior 
vaginal  Avail,  is  softened  and  more  bulging  above  the  cervix,  and  is 
more  easily  grasped  bimanually.  The  partly  filled  bladder  is  depressed 
in  the  centre  or  on  one  side  by  the  heavy  fundus  so  as  to  form  a  broad, 
flattened  fluctuating  tumor. 


EXAMINATION  OF  THE  UTERUS    DURING  GENERAL  ANESTHESIA.       65 

Examination  of  the  Uterus  during  General  Ansesthesia. 

Examined  in  connection  with  the  administration  of  an  ansesthetic 
or  during  an  unusually  relaxed  and  insensitive  state  of  the  tissues, 
the  uterus  can  be  grasped  bimanually  and  turned  in  all  directions. 
By  pushing  the  cervix  back  with  the  finger  in  the  vagina,  the  uterine 
body  may  be  brought  down  upon  the  anterior  vaginal  wall  by  the 
hand  over  the  abdomen,  so  that  the  thickness,  and  the  conformation 
of  its  anterior  and  lateral  walls,  will  be  readily  determined.  Fig.  45 
shows  the  relation  of  the  fingers  to  the  uterus. 


Fig  45. 


Bimanual  Palpation  of  the  Uterus  from  the  Posterior  Vaginal  Wall  (J), 

By  drawing  the  cervix  forward  with  one  or  two  fingers  in  the  vagina 
— first  pressing  upward  in  the  anterior  fornix,  and  then  drawing  for- 
ward under  and  behind  the  free  end  of  the  cervix — and  pushing  the 
fundus  back  with  the  hand  above  the  pubes,  the  cervix  and  lower  por- 
tion of  the  corpus  can  be  grasped  between  the  fingers  outside  and  those 
in  the  posterior  fornix  as  represented  in  Fig.  46. 

When  it  becomes  necessary  to  palpate  the  whole  posterior  wall,  the 

5 


66 


EXAMINATION    OF   THE    FEMALE   PELVIC   OEOAXS. 


vaginal  fingers,  after  the  fundus  has  been  pushed  as  far  back  as  pos- 
sible by  the  external  hand,  may  press  the  lower,  or  free  end  of  the 


Fig.  46. 


Bimanual  Palpation  of  the  Uterus,  through  the  Anterior  Vaginal  Fornix  (J). 


cervix,  up  toward  the  pelvic  brim  and  thus  turn  the  fundus  into  the 
hollow  of  the  sacrum,  or  the  recto-uterine  pouch,  as  represented  in 
Fig.  47. 

The  posterior  wall  of  the  whole  body  will  then  be  accessible.  In 
replacing  the  uterus  the  cervix  is  pulled  down  by  the  finger  upon  it, 
or  drawn  down  by  pressing  the  posterior  fornix  vaginae  toward  the 
coccyx,  and  then  the  fundus  uteri  pushed  up  toward  the  sacral 
promontory.     The  natural  supports,  if  normal,  Avill  do  the  rest. 

In  pushing  the  fundus  backward  into  the  holloAV  of  the  sacrum  we 
must  press  just  over  the  pubes,  so  as  to  get  under  the  fundus  ;  in 
bringing  the  fundus  forAvard  over  the  anterior  vaginal  Avall  Ave  press 
deep  into  the  abdomen  just  under  the  umbilicus  and  then  doAVUAvard 
over  the  fundus. 

The  uterus,  as  thus  felt,  should  be  smooth,  hard  and  slightly  flat- 
tened upon  the  anterior  and  posterior  surfaces,  without  ridges  or  jDro- 


THE   ADVANTAGES    OF   A    GENTLE   TOUCH. 


67 


jections  except  at  the  upper  angles  or  horns,  where  the  Fallopian  tubes 
and  the  ovarian  and  round  ligaments  pass  off  laterally. 


Fig.  47 


Uterus  artificially  turned  back  against  the  hollow  of  the  Sacrum,  for  palpation  of  the 
Posterior  Wall  (J). 

Digital  Exploration  of  the  Pelvic  Roof  through  the  Vagina. 
By  pressing  with  one  hand  firmly  down  over  the  abdominal  walls 
to  one  side  of  the  artificially  anteverted  uterus,  and  with  the  other 
upward  against  the  anterior  vaginal  wall  on  the  same  side,  Ave  may 
make  both  hands  meet  with  only  the  abdominal  and  vaginal  walls, 
and  broad  ligament  with  its  contents,  between  them,  and  palpate 
against  the  external  hand  or  make  the  approximated  fingers  (external 
and  internal)  glide  together  successively  over  small  contiguous  areas 
of  the  pelvic  roof,  until  the  whole  is  explored.  The  skin  and  mucous 
membrane  move  with  the  fingers  and  each  tissue  as  it  slips  between 
them  may  be  recognized  by  its  shape  and  position,  or  be  traced 
throughout  its  course  in  the  pelvis.  In  bimanual  examination  of  the 
right  side  of  the  pelvis  we  should  use  the  right  hand  for  the  vagina, 
for  the  left  side  the  left  hand.  As  a  rule  when  the  fundus  uteri  is  low 
in  the  pelvis  the  abdominal  walls  should  be  depressed  as  much  as 
possible ;  when  the  fundus  is  high  the  vaginal  walls  should  be  pushed 
well  up.  In  this  way  the  parts  are  more  easily  reached,  and  are  not 
much  disturbed  in  their  relations. 

The  Advantages  of  a  Gentle  Touch. 
A  rough  finger  in  the  vagina  may  press  upon  the  tissues  of  the  pel- 
vic roof  a  thousand  times  without  recognizing  them,  while  the  touch 


68  EXAMIXATION    OF    THE    FEMALE    PELVIC   ORGANS. 

of  a  gentle  hand  will  locate  ligaments,  ureters,  bloodvessels  and  nerves 
without  difficulty.  The  so-called  tactus  eruditus  is  in  fact  nothing  but 
a  gentle  attentive  touch  guided  by  a  thorough  knowledge  of  the 
anatomy  of  the  parts.  It  may  be  acquired  by  almost  any  one  in  a 
short  time,  yet  must  remain  forever  out  of  the  reach  of  many  j^rac- 
titioners  and  specialists. 

JJ^en  not  to  Examine. 

There  are  many  cases  in  which  rigidity  of  the  abdominal  walls, 
smallness  of  the  vagina,  rigidity  of  the  perineum,  abnormal  sensitive- 
ness, menstruation,  disease,  etc.,  render  a  thorough  exploration  of  the 
pelvic  roof  unendurable  and  frequently  injurious  or  dangerous.  When 
acute  or  subacute  inflammatory  changes  exist,  a  knowledge  of  the 
location  and  general  character  of  the  inflammation  must  often  suffice 
until  subsequent  improvement  renders  a  thorough  exploration  prac- 
ticable. 

Precautions  Necessary  During  Examination. 

It  is  often  better  to  examine  successive  portions  of  the  pelvis  at 
different  times  (without  anaesthesia)  being  careful  always  to  desist  be- 
fore irritation  is  produced.  Unless  the  patient's  confidence  in  her 
physician  be  well  grounded,  he  will  justly  lose  what  she  may  already 
have  given  him  in  proportion  as  he  hurts  or  injures  her.  It  is  also 
well  to  remember  that,  under  anaesthesia,  not  having  the  patient's 
sensations  to  guide  us,  we  are  es23ecially  liable  to  manipulate  tender 
or  inflamed  tissues  until  irreparable  injury  may  be  done.  We  should, 
therefore,  when  a  complete  exploration  is  necessary,  examine  such 
parts  as  we  can  by  one  or  several  examinations,  with  the  patient's 
feelings  to  guide  us  in  finding  and  avoiding  tender  parts ;  and,  then, 
on  another  occasion,  complete  the  examination  with  the  aid  of  an 
anaesthetic.  The  value  of  an  examination  is  not  in  proportion  to  the 
amount,  but  rather  to  the  intelligence  of  the  manipulations.  Some 
gynecologists  by  their  attempts  at  thoroughness  in  diagnosis  produce 
more  irritation  by  their  fingers  than  their  treatment  can  remove; 
others  with  seemingl}^  superficial  examinations,  yet  adequate  to  the 
end,  are  able  to  quickly  cure  the  patient. 

Difficulty  of  Differentiating  Pelvic  Tissues  by  the  Touch. 

Nothing  would  seem  easier  than  to  approximate  the  fingers  of  the 
two  hands  in  bimanual  examinations  and  locate  each  structure  as  it 
comes  between  them.  Yet  when  we  consider  that  the  round  ligaments, 
ovarian  ligaments,  Fallopian  tubes,  ureters,  inter-uretric  ligaments, 
edge  of  the  collapsed  bladder,  enlarged  lymphatics,  vaginal  cicatrices, 
sacro-uterine  peritoneal  folds,  and  some  aponeurotic  bands  about  the 


HOW  TO  PALPATE  THE  OVAEIES. 


69 


abdominal  muscles,  all  give  more  or  less  the  same  sensation  as  of 
cords  or  ridges  passing  through  the  pelvic  roof;  and  that  one  of  these 
may  be  over  or  almost  parallel  to  another,  we  can  appreciate  the 
doubt  entertained  by  many  as  to  the  possibility  of  differentiating  them. 
Yet  if  we  have  in  our  mind  the  characteristics,  and  different  positions 
and  directions,  of  the  structures  as  they  accommodate  themselves  to 
the  position  of  the  fundus,  and  will  patiently  and  carefully  trace  them 
to  their  attachments  we  may  usually  overcome  the  difficulties. 

The  Starting  Point  in  Digital  Explorations  of  the  Pelvic  Roof. 

The  starting  point,  then,  of  our  explorations  of  the  pelvic  roof 
should  be  the  fundus  uteri  which,  by  carrying  a  portion  of  the  struct- 
ures with  it  in  its  ceaseless  physiological  variations,  and  by  frequent 
pathological  alterations  of  position,  and  twisting,  to  a  greater  or  less 
degree,  the  broad  ligaments  upon  their  transverse  axes,  determines  the 
mutual  relationship  of  nearly  all  of  the  pelvic  structures. 

How  to  Palpate  the  Ovaries. 

(1)  When  the  Fundus  is  in  Front  of  the  Pelvic  Axis. 
If  the  fundus  be  found  in  front  of  the  pelvic  axis,  we  may  find  the 
ovary  (Figs.  10,  12  and  48)  by  introducing  the  index  finger  (two 

Fig.  48. 


Positions  of  Ovaries  as  seen  from  the  Pelvic  Brim  {%).  Modified  from  Schultze. 
a,  fundus  of  uterus  with  empty  bladder ;  b,  fundus  of  uterus  with  full  bladder  ;  e,  horn  of 
uterus  displaced  laterally,  belonging  to  ov'' ;  ip,  infundibulo-pelvic  ligament ;  ot'i,  ordinary  posi- 
tion of  ovary  ;  ov",  ovary  against  the  sacrum  ;  ov^,  ovary  over  lateral  vaginal  fornix  ;  ov»,  ovary 
in  the  pouch  of  Douglas  ;  of",  ovary  in  or  over  the  sacral  pouch  ;  ov',  ovary  in  transverse  position 
by  lateral  traction  of  uterus,  c;  ap,  anterior  superior  spinous  process;  ps,  psoas  muscle. 

fingers  if  the  index  be  short)  to  the  anterior  wall  of  the  cervix,  then 
passing  it  at  right  angles  along  the  anterior  edge  of  the  base  of  the 


70  EXAMINATION    OF   THE    FEMALE    PELVIC   ORGANS. 

broad  ligament  to  the  pelvic  wall,  and  pressing  upward  just  in  front 
of  the  attachment. 

Another  way  to  find  the  ovary  is  to  carry  the  finger  around  the  pelvic 
wall  until  the  obturator  artery  is  felt  (see  Palpation  of  Vessels  and 
Nerves  of  the  Pelvis,  pp.  104,  107),  viz.,  around  the  pubic  attachments 
of  the  levator  ani  to  the  upper  edge  of  the  obturator  muscle  along 
which  the  artery  runs,  and  then  straight  back  along  the  side  wall  of 
the  pelvis  over  the  ischial  spine.  A  little  in  front  of  the  spine,  and 
just  anterior  to  the  resistant  base  of  the  broad  ligament,  the  finger 
when  pressed  upward  above  the  artery  should  touch  the  ovary.  Un- 
usual firmness  of  the  connective  tissue  and  a  free  mobility  of  the  organ 
may,  however,  prevent  its  easy  recognition. 

Another  way  to  find  the  ovary  is  to  trace  the  ureter  to  where  it 
passes  under  the  broad  ligament  (see  Palpation  of  the  Ureters,  p. 
78)  and  press  up  in  the  angle  between  the  ureter  and  the  pelvic 
wall.  A  firmly  placed  ureter  may  run  so  nearly  under  the  ovary  as 
to  prevent  the  finger  reaching  it.  If,  as  must  often  happen,  there  is 
doubt  as  to  whether  the  ovary  is  over  the  finger,  the  other  hand  may 
be  pressed  into  the  abdominal  walls  on  and  below  a  line  connecting 
the  anterior  superior  spinous  processes  of  the  ilea,  and  about  two 
and  a  half  inches  from  the  median  line.  The  fingers  will  thus  come 
against  the  psoas  muscle  passing  over  the  pelvic  brim,  and  if  brought 
inward  toward  the  pelvic  cavity,  will  press  into  it  just  over  the  nor- 
mally located  ovary,  and  form  with  the  depressed  abdominal  walls  a 
resistant  surface  against  which  the  vaginal  finger  can  palpate.  A 
sudden  complaint  of  being  hurt,  or  of  a  sickening  pain,  from  the  pa- 
tient, will  usually  give  us  early  notice  that  we  are  successful  in  our 
search. 

In  case  the  uterus  is  drawn  against  or  over  the  symphysis,  the  ovary 
may  be  found  a  little  farther  forward  (Fig.  G,ov^). 

Or  it  may  be  found  farther  back  just  over  the  outer  end  of  the 
base  of  the  forward  leaning  broad  ligament.  The  finger  then  finds  it 
by  pressing  up  back  instead  of  in  front  of  the  base  of  the  ligament 
(Fig.  6,  ov^).  This  position  of  the  ovary  is  not  uncommonly  found  on 
one  side  when  the  fundus  is  farther  back  than  normal,  and  the  broad 
ligament  of  the  same  side  is  slightly  shortened ;  or  on  both  sides  when 
the  sacro-uterine  ligaments  hold  the  middle  of  the  uterus  well  back, 
and  the  fundus  curves  forward  yet  remains  elevated  from  the  pubes 
and  anterior  vaginal  wall.  In  the  first  case  the  ovarian  and  infundi- 
bulo-pelvic  ligaments  are  relaxed,  in  the  second  the  upper  parts  of 
the  broad  ligaments  are  either  slightly  relaxed  or  shortened  (since  the 
corpus  uteri  is  more  directly  in  a  line  between  their  peripheral  attach- 
ment). The  ovary  in  either  case  sags  down  but  is  kept  in  almost  its 
normal  axis  by  normal  abdominal  pressure. 

Occasionally  the  ovary  sinks  downward  and  forward  and  lies  against 


HOW   TO    PALPATE   THE    OVARIES.  71 

or  over  the  obturator  artery  and  the  white  line  of  insertion  of  the 
levator  ani  into  the  fascia  of  the  obturator  muscle.  It  can  then,  if 
not  too  tender,  be  easily  caught  between  the  finger  and  the  pelvic  wall 
in  front  of  the  base  of  the  broad  ligament  without  pushing  up  toward 
the  pelvic  lDrim,  as  is  necessary  in  palpating  the  normally  located 
ovary.  Especially  is  this  so  on  account  of  the  flabbiness  of  the  tis- 
sues that  usually  accompanies  such  disj)lacement. 

When  the  ovary  leaves  the  lateral  pelvic  wall  it  may  often  be  found 
beside  the  cer\dx,  just  over  the  lateral  fornix  vaginee  (Fig.  10,  ov^  and 
48,  ov^),  and  is  detected  by  pressing  the  finger  up  beside  the  fornix  with 
or  without  a  forcing  of  the  abdominal  walls  down  over  it  by  the  ex- 
ternal hand. 

Another  not  very  rare  place  to  find  the  ovary  is  the  recto-uterine 
cul-de-sac  of  Douglas  (Fig.  48,  ov^).  It  may  then  be  felt  behind  the 
posterior  or  lateral  vaginal  fornix  and  usually  hanging  over  the  sacro- 
uterine fold  of  the  side  from  whence  it  came. 

Finally  the  ovary  may  be  found  floating  or  hanging  back  in  or  over 
the  sacral  peritoneal  pouch,  neither  against  the  lateral  nor  jiosterior 
wall  of  the  pelvis  (Fig.  48,  ov^).  It  is  palpated  here  with  great  diffi- 
culty per  vaginam.  But  if  enlarged  and  accompanied  by  a  relaxed 
pelvic  roof  it  may  occasionally  be  felt  somewhat  as  the  foetal  head  is 
felt  by  ballottement.  Although  it  does  not  settle  upon  the  finger  as  dis- 
tinctly as  does  the  head,  yet  by  successive  touches  it  is  each  time 
detected  back  from  where  it  had  receded  at  the  previous  touch. 

(2)  When  the  Fundus  lies  against  or  near  the  Sacrum. 

When  the  fundus  is  in  the  back  part  of  the  pelvis  the  ovary  often 
lies  back  transversely  on  either  side  of  the  fundus  in  the  bottom  of 
the  sacral  peritoneal  pouch  (Fig.  6,  ov^)  or  against  the  sacrum  (Fig. 
48,  ov^),  and  if  the  vagina  be  sufficiently  relaxed  it  may  be  palpated 
against  the  posterior  pelvic  wall  by  the  finger,  or  fingers,  pressed  back 
and  high  up  on  either  side  of  the  fundus. 

When-  in  the  recto-uterine  pouch  (or  cul-de-sac  of  Douglas),  it  is  felt 
under  the  body  of  the  retroplaced  uterus,  slippery  to  the  touch  but 
confined  in  its  motions  to  the  space  in  which  it  is  held. 

The  ovary  may  in  other  cases  be  felt  over  the  lateral  fornix  by  the 
finger  pushed  high  up  l)eside  the  corpus,  especially  if  the  abdominal 
walls  be  depressed  by  the  hand  externally  (Fig.  12,  ov'  and  10,  ov^). 

(3)  When  the  Fundus  is  displaced  toward  one  side  of  the  Pelvis. 
When  the  fundus  is  drawn  toward  one  side  of  the  pelvis,  the  ovary, 

on  the  same  side,  sagging  backward  or  forward  from  a  relaxation  of  its 
ligaments,  is  often  reached  with  difficulty  because  of  the  greater  density 
of  the  contracted  tissue  under  it.  Upon  the  opposite  side  the  anterior 
end  is  often  drawn  with  the  uterus  towards  the  middle  so  that  the  organ 
lies  somewhat  transversely  across  the  upper  part  of  the  broad  liga- 
ment.    Its  supports  being  drawn  a  little  more  tense,  it  is  more  firmly 


72  EXAmXATIOX    OF    THE    FEMALE    PELVIC   OEGAXS. 

held,  and  hence  more  easil}^  palpated.     Fmally,  the  ovary  may  be 
found  at  the  inguinal  ring. 

We  may  thus  find  the  ovary  in  eleven  different  positions,  viz..  four 
against  the  side  wall  of  the  pelvis — ^the  parietal ;  two  about  the  cervix 
— the  central ;.  two  in  and  one  above  the  sacral  peritoneal  pouches — 
the  posterior ;  one  turned  across  the  side  of  the  peMs — the  transverse. 

Tahle  of  Position  of  Ovaries. 
I.  Parietal  : 

1.  Normal. 

2.  Displacement  forward. 

3.  Displacement  backward. 

4.  Displacement  downward. 
II.  Central  : 

5.  Over  lateral  vaginal  fornix. 

6.  In  the  recto-uterine  or  Douglas  pouch. 

III.  Posterior: 

7.  At  the  bottom  of  the  sacral  pouch. 

8.  Against  the  sacrum. 

9.  Floating  over  the  sacral  pouch  (changeable). 

IV.  Transverse  : 

10.  Extending  across  the  side  of  the  pelvis  between   the 

psoas  muscle  and  the  displaced  uterine  horn. 
V.  Extea-Abdomixal  or  Herxlil  : 

11.  At  the  inguinal  ring. 

In  the  parietal  positions  the  long  axis  of  the  ovary  is  only  slightly 
changed,  in  the  other  positions  it  is  greatly  changed  by  a  swinging  of 
the  organ  upon  the  lateral  attachment. 

A  lump  of  fseces  has  been  mistaken  for  an  ovary  in  or  near  the  recto- 
uterine cul-de-sac.  This  mistake,  although  easily  made,  may  be 
avoided  by  remembering  that  a  lump  of  faeces  in  the  rectum  is  neither 
so  smooth,  tender,  elusive  to  the  touch  as  the  ovary,  nor  pro%Tided  with 
ligaments.  A  fecal  mass  can  be  displaced  only  with  the  rectal  folds 
about  it,  but  can  be  worked  in  part  down  into  the  lower  rectum,  can 
usually  be  mashed  by  moderate  pressure  and  without  pain,  and  is  apt 
to  be  accompanied  by  one  or  more  lumps  above  or  below  it,  along  the 
course  of  the  \uscus. 

Palpation  of  the  Ovarian  Ligament. 

The  chief  value  of  palpation  of  the  ovarian  ligament  lies  in  the  fact 
that  it  leads  to  the  anterior  or  inner  end  of  the  ovary,  and  that  the 
Fallopian  tube  may  usually  be  found  floating  above  it,  or  not  far  off. 
It  is  of  firm  fibrous  structure,  short  and  ciuite  inelastic.    It  feels  larger, 


THE   IXFUXDIBULO-PELVIC   LIGAMEXT.  73 

harder,  and  more  resistant  than  the  round  ligament,  Fallopian  tube,  or 
ureter,  to  bimanual  palpation. 

When  the  fundus  is  forward  we  may,  by  moving  the  bimanually 
approximated  fingers  of  both  hands  slowly  forward  beside  the  uterus, 
feel  the  ligament,  as  it  is  pulled  forward,  suddenly  slip  from  the  grasp 
back  to  its  position,  and  away  from  the  fingers,  with  a  jerk  or  snap 
that  is  so  decided  as  to  be  almost  characteristic.  This  almost  trans- 
verse direction  of  the  ligament  with  the  fundus  forward  shows  the 
ovary  to  be  normally  forward  (Fig.  48,  ov^),  and  but  little,  if  at  all,  out 
of  place.  A  more  diagonal  direction  of  the  ligament  indicates  a  sag- 
ging back  of  the  ovary  (Fig.  6,  of^),  or  a  leaning  forward  of  the  fundus 
uteri  (Fig.  6,  ov^). 

When  the  ovary  lies  beside  the  cervix  the  ligament,  although  not 
easily  accessible,  may  be  felt  passing  along  beside  the  uterus  from  the 
fundus  to  the  cervix,  whether  the  fundus  be  forward  (Fig.  48,  ov^,  and 
Fig.  10,  oi'O,  or  backward  (Fig.  10,  ov'^).  When  the  ovary  lies  in 
the  recto-uteriue  pouch  the  ligament  will  curve  around  beside  the 
uterus  toward  the  fundus,  and  ma}'  be  felt  passing  over  the  correspond- 
ing recto-uterine  peritoneal  fold  (Fig.  48,  ov*).  When  the  fundus  is 
back  in  the  pouch  of  Douglas  the  ligament,  although  relaxed,  may  be 
palpated  against  the  uterus  over  it  or  the  sacro-uterine  ligament  beside 
it.  When  the  fundus  and  ovary  lie  against  the  sacrum  the  ligament 
may  be  felt  connecting  them  by  pressing  the  finger  back  against  the 
sacrum  beside  the  fundus.  When  the  ovary  floats  over  the  posterior 
lateral  peritoneal  pouch  the  ligament  can  seldom  be  detected  unless 
the  ovary  can  be  pressed  back  against  the  sacrum  or  pulled  forward 
with  the  fundus  and  palpated  bimanually  beside  the  corpus  uteri.  It 
then  goes  from  ov".  Fig.  48,  to  positions  corresponding  to  that  repre- 
sented on  the  oj^posite  side  by  ov^  and  ov^. 

The  Infundibulo-Pelvic  Ligament. 

The  infundibulo-pelvic  ligament  may  in  some  instances  be  palpated. 
When  the  ovary  lies  at  the  side  of  the  pelvis  the  fimbriated  extremity 
of  the  Fallopian  tube  serves  as  a  guide  to  it,  and  can  occasionally  be 
traced  to  it,  and  recognized  bimanually  as  a  ribbon-like  fold  extend- 
ing to  the  belly  of  the  psoas  muscle  at  the  side  of  the  pelvic  brim. 
When  the  ovary  lies  in  the  pouch  of  Douglas  it  may  be  felt  passing 
from  the  ovary  over  the  sacro-uterine  ligament  along  with  the  larger, 
harder,  but  more  relaxed  ovarian  ligament.  When  the  ovary  is  against 
the  sacrum,  or  low  in  the  posterior  lateral  peritoneal  pouch,  the  infun- 
dibulo-pelvic ligament  may  occasionally  be  palpated  against  the  pelvic 
wall  by  hooking  the  finger  over  it  just  external  to  the  ovary.  When 
both  this  and  the  ovarian  ligament  proper  are  traced  to  or  from  the 
ovary,  the  place,  position  and  relation  of  that  organ  is  determined,  and 


74  EXAMINATION    OF    THE    FEMALE    PELVIO    ORGANS. 

the  condition  of  the  upper  and  outer  portion  of  the  broad  ligaments 
may  be  inferred,  especially  when  taken  in  connection  with  the  condi- 
tion of  the  round  ligament. 

Palpation  of  the  Round  Ligament. 

As  the  round  ligament  is  high  up  in  the  pelvic  roof,  and  composed 
of  muscular  tissue,  it  offers,  unless  contracted  or  unusually  tense,  only 
an  indistinct  sensation  of  resistance  to  the  finger  in  the  vagina. 
Bimanually,  however,  it  is  easily  found  running  almost  straight  out- 
Avard  from  under  the  uterine  horn,  and  assuming  a  constantly  increas- 
ing curve  forward  until  behind  the  internal  inguinal  ring,  when  it 
passes  almost  directly  forward  into  it.  It  feels  somewhat  larger  when 
contracted  than  when  relaxed,  seldom  quite  as  large  as  the  ovarian 
ligament,  and  does  not  slip  with  such  a  decided  snap  through  the 
fingers  and  out  of  the  way.  When  relaxed  it  sags  outward  and  forms 
a  larger  curve,  thus  tending  to  get  out  of  reach  of  the  vaginal  finger 
(see  Fig.  6). 

On  account  of  the  frequent  difficulty  experienced  in  differentiating 
it  from  the  structures  about  it,  we  will  briefly  indicate  how  to  pick  it 
up  bimanually  and  trace  it  from  the  internal  abdominal  ring  to  the 
uterine  horn.  The  internal  abdominal  ring  is  at  the  pelvic  brim  about 
as  far  from  the  pubic  arch  or  vaginal  entrance  as  the  index  finger  can 
conveniently  reach,  and  as  high  or  a  little  higher  than  the  natural 
resistance  of  the  tissues  will  allow  it  to  go.  If  we  insert  the  index 
finger  of  our  right  hand  into  the  vagina,  and  slip  it  upon  the  posterior 
surface  of  the  right  pubic  bone  along  the  upper  edge  or  pubic  attach- 
ment of  the  levator  ani,  we  will  come  upon  the  groove  of  the  white 
line  or  reflection  of  obturator  fascia  (Fig.  17)  forming,  where  it  strikes 
the  bone,  a  distinct  depression  or  fossa.  Above  and  just  external  to 
this,  the  round  ligament  passes  into  the  ring ;  and  if  it  be  contracted 
and  firm  may  be  felt  as  a  ridge  passing  backward  from  the  ring  by 
pressing  up  the  point  of  the  finger  to  the  pelvic  brim  and  then  veering 
it  outward  as  far  as  possible.  But  on  account  of  the  sensitiveness  of 
the  parts  thereabout,  the  resistance  of  the  displaced  tissues  and  tVie 
mobility  of  the  ligament,  it  is  advisable  to  depress  the  pelvic  roof  and 
inguinal  ring  toward  the  finger.  Accordingly  we  press  with  the  out- 
side hand  down  over  Poupart's  ligament  from  two  to  two  and  a  half 
inches  (about  four  fingers'  breadth)  from  the  pubic  spine  until  the  liga- 
ment comes  within  reach  of  the  finger  inside.  The  ring  may  some- 
times be  recognized  by  the  pulsations  of  the  epigastric  artery  under 
it  and  extending  up  the  abdominal  wall,  but  most  usually  b}^  the 
round  ligament  itself  as  palpated  against  the  depressed  tissues.  The 
most  satisfactory  way  is  to  thus  approximate  the  fingers  of  the  two 
hands,  and  move  them  sideways  until  the  ligament  slips  between 
them,  and  then  trace  it  forward  and  around  its  curve,  always  moving 


PALPATION    OF   THE    ROUND    LIGAMENT. 


iO 


the  fingers  at  right  angles  to  it.  The  amount  of  tension  and  degree  of 
curvature  of  its  outer  end  will  usually  enable  us  to  calculate  the  rest 
of  its  course  to  the  uterine  horn.  When  relaxed  it  seems  farther  from 
the  symphysis  and  is  not  so  readily  made  to  slip  through  the  bimanual 
grip.  Fig.  6  shows  the  difference  in  the  curves  of  the  contracted  and 
relaxed  ligaments.  They  may  sometimes  be  made  tense,  and  palpated 
through  a  voluminous  vagina  by  hooking  the  lower  end  of  the  cervix 
forward  with  the  index  finger,  thus  prying  back  the  fundus  upon  the 


Fig.  49. 


Artificial  Tension  of  the  Round  Ligament,  using  the  Sacro-uterine  Attachment  as  a  Fulcrum  Q/Q. 
r,  round  ligaments  ;  su.  sacro-uterine  ligaments ;  u,  uterus. 


sacro-uterine  attachments  as  a  fulcrum  and  then  pressing  the  middle 
finger  toward  the  side  of  the  pelvic  roof.  (See  Fig.  49.)  The  external 
hand  may  be  made  to  increase  the  tension  by  pressing  into  the  ab- 
dominal walls  just  above  the  pubes  and  then  upward  under  and  against 
the  fundus.  When  the  ligaments  are  contracted  so  as  to  be  firmer  than 
the  sacro-uterine  ligaments,  the  fundus  in  the  above-mentioned  mani- 
pulation becomes  the  fulcrum  and  the  whole  lower  end  of  the  uterus, 


76 


EXAMINATION    OF    THE    FEMALE    PELVIC    OEGANS. 


instead  of  only  the  external  os,  will  be  pulled  toward  the  vaginal  out- 
let. Contraction  of  the  round  ligament  may  be  thus  recognized,  and 
also  by  several  other  signs.  The  fundus  lies  behind,  or  over,  and  very 
near  the  pubes  (Fig.  50)  and  presents  a  resistance  to  upward  pressure 
behind  the  pubic  arch  much  greater  than  its  weight,  yet  one  which 
readily  yields  to  steady  pressure.  The  upper  portion  of  the  broad 
ligament  is  rendered  tense  as  indicated  by  the  firmness  of  the  pelvic 
roof  or  either  side  of  the  fundus  behind  the  body  of  the  pubis,  and 
sometimes  by  a  ridge  corresponding  to  the  course  of  the  ligament. 

Fig.  50. 


Position  of  Uterus  produced  by  contraction  of  the  Round  Ligaments  Q). 
pubes.    (Case  21,  ofBce  record  of  1886,  Mrs.  W.) 


Fundus  behind 


When  the  contraction  is  extreme  even  the  base  of  the  broad  ligament 
on  either  side  of  the  internal  os  is  felt  to  be  drawn  into  a  characteristic 
prominent  ridge. 

Contraction  of  only  one  ligament  draws  the  fundus  and  body 
toward  the  same  side,  and  points  the  external  os  toward  the  opposite 
side  of  the  pelvis. 

When  the  fundus  lies  against  the  hollow  of  the  sacrum  the  round 
ligament  may  be  trnced  bimanually  from  the  internal  abdominal  ring 
almost  straight  back  to  where  it  passes  over  the  twisted  broad  liga- 
ment (Fig.  6,  hr  and  hrc) ;  and  occasionally  may  be  traced  forward  from 
the  uterine  horn  near  the  sacrum  to  the  base  of  the  broad  ligament. 


PALPATION  OF  THE  FALLOPIAN  TUBES.  77 

The  ovarian,  round,  and  infundibulo-pelvic  ligaments,  ureters,  arteries,  Fallopian 
tubes,  etc ,  are  larger  in  life  than  in  death,  on  account  of  the  blood  in  them,  and  seem 
still  larger  to  the  vaginal  touch  from  being  covered  by  the  vagina  and  layers  of  peri- 
toneum or  connective  tissue.  Contraction  also  increases  their  apparent  size  to  the 
touch. 

Palpation  of  the  Fallopian  Tubes. 

When  the  fundus  uteri  is  forward  behind  the  pubes  and  the  ab- 
dominal walls  lax,  the  Fallopian  tubes  may  be  quite  easily  felt  bi- 
manually.  From  their  uterine  ends,  which  are  then  over  the  lateral 
edges  of  the  empty  bladder,  they  pursue  a  slightly  serpentine  course 
over  the  paravesical  pouches  to  the  sides  of  the  pelvis,  where  they 
curve  backward  toward  the  ovary  (Fig.  12,  ov^).  Bimanually  they  are 
felt  to  be  soft  flabby  cords,  with  apparently  several  twists  or  zigzags  in 
them,  which  are  characteristic.  They  yield  to  forward  or  backward 
traction  (bimanually)  without  that  feeling  of  elasticity  or  firm  resist- 
ance which  causes  the  round  and  ovarian  ligaments  to  return  rapidly 
to  the  position  from  which  they  are  drawn,  but  with  a  characteristic 
drag  upon  their  broad  ligament  attachment.  We  may  differentiate 
them  from  the  edge  of  the  bladder  by  tracing  them  laterally  or  pos- 
teriorly around  a  long  curve  whose  convexity  is  forward,  instead  of  a 
short  curve  whose  convexity  is  backward,  by  their  greatest  resistance 
to  forward  traction,  instead  of  backward,  by  their  entire  independence 
of  the  folds  of  the  bladder,  and  by  their  attachments  to  the  fundus 
uteri. 

When  the  fundus  is  not,  or  cannot,  be  pressed  forward  behind  the 
pubes,  the  tubes  are  farther  removed  from  the  abdominal  wall  mova- 
ble, flabby,  and  sometimes  surrounded  by  intestinal  loops.  Such  is 
probably  the  most  natural  position.  If  the  uterine  horn  and  position 
of  the  ovary  has  been  found,  we  may  calculate  that  the  tubes  will 
pass  in  a  curve  between  it,  a  little  in  front  of  the  shorter  and  straighter 
ovarian  ligaments. 

By  placing  two  fingers  in  the  vagina,  one  upon  each  side  of  the 
cervix,  and  pressing  as  high  up  as  possible,  the  middle  finger  may 
often  be  approximated  to  those  externally  pressed  down  into  the 
abdominal  walls  and  then  all  pulled  forward  together.  The  ovarian 
and  round  ligament,  and  then  the  Fallopian  tube,  may  thus  be  made 
to  slip  between  the  fingers,  like  three  cords  of  progressively  diminish- 
ing size  and  elasticity.  Even  when  these  structures  lie  directly  over 
each  other  (or  together),  the  shortness  and  rigidity  of  the  ovarian 
ligament  causes  it  to  become  tense  and  slip  between  the  fingers  first, 
while  the  flabbiness  of  the  tubes  usually  permits  them  to  be  drawn 
forward  so  as  to  escape  last. 

If  the  ovary  and  fundus  uteri  be  situated  posteriorly,  so  will  ordi- 
narily the  Fallopian  tube  (Fig.  12,  o-y^),  and  may  often  be  palpated 
against  the  sacrum.     If  the  fundus  be  forward  and  the  ovary  back. 


78  EXAIIINATIOX    OF    THE    FEMALE    PELVIC   ORGANS. 

(Fig.  12,  ov^),  or  the  fundus  back  and  the  ovary  forward  beside  the 
cervix  (Fig,  12,  ov^),  the  tube  will  pass  backward  or  forward  from  the 
uterine  horn  toward  the  ovary,  either  almost  directly  over  the  ovarian 
ligament  or  a  little  external  to  it.  If  the  fundus  be  forward  or  central, 
and  the  tube  extend  into  one  of  the  sacral  peritoneal  pouches,  its 
fimbriated  end  may  sometimes  be  pushed  back  upon  the  sacrum 
where  its  irregular  contour  can  be  easily  appreciated.  Whether  the 
fundus  be  forward  or  backward,  the  fimbriated  extremity,  or  a  loop 
of  the  Fallopian  tube,  may  be  felt  hanging  over  a  sacro-uterine 
fold  into  the  pouch  of  Douglas.  Its  length,  limpness,  and  slightly 
irregular  or  undulating  course  over  the  sacro-uterine  ligament,  will 
distinguish  it  from  the  ovarian  ligament.  By  bringing  the  fundus 
well  forward,  and  then  dragging  the  tube  forward  bimanually,  it  may 
in  some  cases  be  brought  anteriorly  from  the  sacro-uterine  into  the 
para-vesical  pouch,  and  there  palpated. 

In  a  general  way  it  may  be  said,  that  if  the  ovarian  ligament  be 
first  found,  the  tube  being  longer  and  looser,  will  be  found  in  front  of 
it  when  the  fundus  uteri  and  broad  ligament  are  forward,  so  as  to 
receive  the  abdominal  pressure  on  their  posterior  surfaces ;  behind  or 
above  it  when  the  parts  are  back  so  as  to  receive  the  abdominal  pres- 
sure on  their  anterior  surfaces ;  or  floating  over  it  before  or  behind, 
indifferently  or  alternately,  when  the  pressure  is  parallel  to  the  long 
axis  of  the  uterus. 

Of  all  the  normal  tissues  of  the  pelvic  roof  which  may  be  said  to 
be  always  or  almost  always  palpable,  the  normal  Fallopian  tubes  are 
probably  the  most  difficult  to  detect.  When  hardened  or  enlarged, 
however,  they  are  proportionately  easy.  The  following  table  of  the 
positions  in  which  the  non-adherent  tube  is  most  frequently  found, 
may  be  useful  to  the  student : 

1.  Normal. 

2.  In  or  over  the  para-vesical  pouch. 

3.  Upon  the  posterior  surface  of  the  broad  ligament. 

4.  In  or  over  the  sacral  pouch. 

5.  In  the  retro-uterine  pouch. 

Palpation  of  the  Ureters. 

When  surrounded  by  healthy  tissue  the  ureters,  at  their  lower  or 
pelvic  portions,  are  among  the  most  readily  and  uniformly  palpable 
of  the  smaller  tissues  of  the  pelvic  roof — much  more  so  than  the 
ovary^  the  ovarian  and  round  ligaments.  Fallopian  tube,  arteries, 
nerves,  etc. 

In  seventy-five  consecutive  gynecological  cases  in  office  practice  the  ureters  were 
examined  by  simple  vaginal  indagation,  with  the  following  results:  At  least  one 
■ureter  was  recognized  in  every  patient:  both  were  felt  in  all  but  eight,  i.e.,  142  of  the 


HOW  TO  FIND  THE  URETERS  WITH  CERVIX  IN  NORMAL  POSITION.     79 

150  ureters.  Of  the  eight  not  felt,  two  belonged  to  the  right,  and  six  to  the  left  side. 
The  causes  of  failure  to  recognize  them  were  chiefly  tenderness,  induration,  contrac- 
tion, cicatrization  and  tension  of  the  vaginal  walls  or  contiguous  connective  tissue. 
In  three  of  the  cases  the  os  was  drawn  back  from  3J  to  4  inches  from  the  inferior 
pubic  ligament;  in  four  cases  it  was  turned  forward  by  backward  displacement  of  the 
fundus;  in  one  case  the  ureter  was  displaced  By  a  tumor  growing  from  the  uterus. 
The  ureters  are  easily  felt  during  pregnancy,  for  several  reasons:  such  as  increased 
tension  produced  by  the  sinking  of  the  uterus  and  broad  ligament  upon  them  ;  soften- 
ing of  hard  tissues  under  them ;  apparent  increase  in  their  volume  due  to  the  serous 
infiltration  and  vascular  turgescence  in  and  about  them;  and  later,  the  presence  of  an 
enlarged  uterus  against  which  to  palpate  them. 

How  to  find  the  Ureters  ivith  Cervix  in  Normal  Position. 

Having  touched  the  anterior  wall  of  the  cervix,  the  index  finger  is 
brought  forward  along  the  anterior  vaginal  wall,  from  an  inch  to  an 
inch  and  a  half,  until  the  inter-uretric  ligament  is  felt  passing  across. 

Fig.  51. 


Positions  of  Ureters  {}4)-    Schematic. 
Those  on  the  right  side  are  relaxed ;  those  on  the  left  are  somewhat  tense.  •  a,  belongs  with 
cervix  displaced  backward;  b,  belongs  with  cervix  in  about  normal  position;  c,  to  cervix  dis- 
placed forward  and  upward  with  fundus  turned  into  the  hollow  of  the  sacrum  (retroversion), 
ai,  &i,  ci,  same  as  a,  6,  c,  but  relaxed. 

If  this  be  not  felt  the  place  where  the  smooth  soft  upper  end  of  the 
anterior  vaginal  wall  merges  into  the  rougher  and  firmer  lower  portion 
indicates  about  where  it  lies.  From  the  end  of  the  inter-uretric  liga- 
ment, viz.,  a  point  about  half  an  inch  to  the  side  of  the  median  line 
the  ureter  is  felt  to  run  as  an  elastic  cord,  seemingly  the  size  of  a  small 
goose  quill,  almost  straight  towards  the  ischial  spine,  where  it  curves 
up  under  and  behind  the  broad  ligament.  The  finger  end  pressed 
gently  (sometimes  firmly)  up  into  the  yielding  parametric  tissue 
beside  the  cervix,  and  hooked  or  drawn  forwards  toward  the  pubic 


80  EXAMINATION   OF   THE    FEMALE    PELVIC    OEGANS. 

bone  of  the  same  side,  will  readily  feel  the  ureter  slip  over  it,  marking 
the  boundary  between  the  softer  parametrium  and  the  harder  periph- 
eral zone  of  fat-containing  connective  tissue.  Sometimes  by  placing 
the  side  of  the  finger  flat  along  the  course  of  the  ureter  w^e  may  feel 
quite  a  stretch  of  it  at  once.  The  pulsation  of  the  middle  vesical 
artery,  which  lies  near  it,  and  is  often  large  enough  and  near  enough 
to  the  vaginal  mucous  membrane  to  be  felt  at  the  same  time,  may,  by 
the  hasty  finger,  be  mistaken  for  it.  Fig.  51,  h  and  6^,  shows  approxi- 
mately the  j)osition  of  the  ureters  when  the  cervix  is  in  a  normal 
position. 

Palpation  of  the  Ureters  v)hen  the  Cervix  is  Displaced  Backward. 

AVhen  the  cervix  is  drawn  far  back  in  the  joelvis,  the  base  of  the 
trigone  usually  follows  the  cervix,  and  allows  the  ureter  to  retract 
into  a  quite  firm  cord  easily  felt  (Fig.  51,  a  and  a^).  When,  however, 
the  trigone  does  not  follow  back  the  cervix,  the  ureter  drawn  upon  by 
the  retroposed  base  of  the  broad  ligament,  is  stretched  and  attenu- 
ated, and  having  a  stretched  firm  parametric  tissue  behind  it  cannot 
always  be  as  readily  recognized.  By  pressing  up  along  the  lateral 
edges  of  the  uterine  body  (which  in  this  case  is  generally  turned 
forward)  the  lower  end  of  the  ureter  may  be  got  between  the  finger 
tip  and  the  uterus  as  if  it  were  a  small  cord,  and  then  be  traced 
laterally. 

Palpation  of  the  Ureter  ivhen  the  Cervix  is  Displaced  Forwards. 

When  the  cervix  is  displaced  forward,  the  lower  edge  of  the  broad 
ligament,  drawn  forward  with  the  cervix,  usually  relaxes  the  ureter, 
and  permits  it  and  the  base  of  the  trigone  to  sag  forwards  over  the 
relaxed  vaginal  walls  so  as  not  to  be  felt  in  its  ordinary  place  (Fig.  51, 
c  and  &).  Its  flabby  condition  may  also  prevent  it  being  recognized 
when  pressed  upon  by  the  finger.  In  such  case  it  may  be  hooked 
forward  toward  the  pubes  and  rendered  tense,  or  hooked  against  the 
pubes,  under  the  bladder,  and  palpated  upon  the  inner  surface  of  the 
anterior  pelvic  wall ;  then  traced  upon  the  pelvic  walls  around  to  the 
base  of  the  broad  ligament,  and  from  there  back  across  the  trigone  to 
the  opposite  side. 

The  bimanual  examination  is  seldom  necessary  for  finding  the 
ureter,  although  it  is  very  easily  palpated  in  this  way.  On  account 
of  being  felt  first  and  easiest  it  is  liable  to  be  mistaken  for  other  tis- 
sues sought,  but  other  tissues,  except  an  artery  or  a  cicatrix,  are  sel- 
dom mistaken  for  it.  In  bimanual  palpation  of  the  other  structures 
of  the  pelvic  roof  it  is  desirable,  in  order  not  to  disturb  their  relations, 
to  press  the  finger  in  the  vagina  well  up  into  the  pelvic  roof  where 


PALPATIOX    OF   THE    BROAD    LIGAMENTS.  81 

they  lie,  while  in  that  of  the  ureter  it  is  better  to  press  the  hand  over 
the  abdomen  well  down  into  the  pelvic  cavity  near  where  it  lies. 

Differentiation. 

The  ureters  are  easily  known  from  other  structures  of  the  pelvic 
roof  by  being  found  so  near  to  the  vaginal  walls ;  by  being  traceable 
forward  to  and  across  the  trigone  instead  of  to  a  uterine  horn,  as  the 
round  and  ovarian  ligaments  and  Fallopian  tube  ;  by  ]3assing  under 
the  base  of  the  broad  ligament  instead  of  over  it,  as  do  the  round  and 
ovarian  ligaments,  and  Fallopian  tube  ;  and  by  their  direction,  which 
is  normally  more  nearly  backward  than  these  other  structures.  In  a 
forward  position  of  the  cervix  with  a  turning  back  of  the  fundus  the 
ureters  are  dis]3laced  forward,  and  often  palpable  against  the  pubis, 
while  the  other  structures  of  the  pelvic  roof  are  displaced  backward, 
and  sometimes  palpable  against  the  sacrum. 

•    Palpation  of  the  Broad  Ligaments. 

(1)  The  Upper  or  Uterine  Portions. 

The  absence  of  intestinal  loops  in  the  para- vesical  peritoneal  pouches 
while  the  patient  is  in  the  dorsal  position  indicates  that  the  up|)er  parts 
of  the  broad  ligaments  are  forward;  while  the  presence  of  any  con- 
siderable amount  of  intestine  felt  anteriorly  and  causing  a  bulging 
down  of  the  pelvic  roof  on  either  side  indicates  that  the  upper  por- 
tions are  either  relaxed  or  forced  back,  or  both. 

As  the  upper  portions  of  the  ligaments  are  not  easily  felt,  we  must 
often,  in  order  to  determine  their  position  and  condition  more  defi- 
nitely, locate  their  internal  or  changeable  uterine  attachments,  and 
the  tissues  which  pass  through  or  over  them  to  their  external  fixed 
ends. 

When  the  fundus  is  forward  while  the  cervix,  the  ovary  and  its  liga- 
ment, the  Fallopian  tube,  and  the  uterine  end  of  the  round  ligament 
are  in  their  normal  positions,  so  must  be  the  broad  ligament.  It  thus 
receives  the  greatest  amount  of  abdominal  pressure  upon  its  posterior 
surface.  When  the  fundus  is  high  out  of  reach  above  the  vesico- 
vaginal septum,  the  ovary  beside  a  normally  located  cervix,  the  Fal- 
lopian tube  curving  back  or  over  it,  and  the  round  ligament  extending 
from  the  abdominal  ring  in  a  slight  curve  to  one  side  of,  or  back  of, 
the  pelvic  axis,  the  broad  ligament  is  relaxed  and  receives  the  prin- 
cipal abdominal  pressure  almost  in  the  direction  of  the  uterine  axis. 
When,  however,  the  cervix  has  settled  down  within  half  an  inch  or 
so  of  the  coccyx,  but  the  ovary  and  the  tube  normal  in  position  and 
the  round  ligament  firm,  the  upper  23ortion  although  necessarily  carried 
down  with  the  depressed  uterus  is  stretched  rather  than  relaxed. 
When  the  whole  uterus  and  its  appendages  are  pressed  back  against 

6 


82  EXAMINATION    OF    THE    FEMALE    PELVIC    ORGANS. 

or  near  the  sacrum,  and  the  round  ligament  lax,  and  the  uterus 
straight,  the  upper  portion  of  the  broad  ligament  must  be  relaxed 
and  receive  the  abdominal  pressure  mainly  upon  its  anterior  sur- 
face. 

Lateral  displacement  of  the  fundus  with  contraction  of  the  upper 
part  of  the  ligament  is  recognized  by  a  hardening  beside  the  horn 
holding  it  with  more  or  less  rigidity  ;  lateral  displacement  with  relaxa- 
tion is  known  by  the  flabbiness  beside  the  horn  and  the  sagging  back 
of  the  ovary  and  tube.  Tension  of  the  ligament  opposite  the  dis- 
placed fundus  is  known  by  the  tension  and  transverse  direction  of  the 
ovarian  ligament  drawing  the  uterine  end  of  the  ovary  away  from  the 
pelvic  wall,  the  more  diagonal  direction  of  the  round  ligament  bring- 
ing it  nearer  the  vaginal  entrance,  and  the  ease  of  recognition  of  the 
appendices.  A  general  tension  of  the  ligament  is  in  such  cases  recog- 
nizable unless  the  vaginal  tube  be  narrow. 

When  the  cervix  is  forward  and  the  fundus  in  the  hollow  of  the 
sacrum,  the  broad  ligament  is  twisted  upon  its  transverse  axis  and 
receives  the  abdominal  pressure  entirely  upon  its  anterior  surface. 
If,  at  the  same  time,  the  ovary  and  its  ligament  be  against  the  sacrum 
the  upper  uterine  portion  must  be  relaxed  or  stretched.  When  the 
fundus  is  drawn  or  pressed  back  against  the  sacrum  and  the  os  for- 
ward, and  the  broad  ligaments  at  the  same  time  held  forward,  the 
ovarian  ligament  will  pass  forward  to  the  ovary,  which  will  be  beside 
the  cervix  (Fig.  12,  ov")  or  floating  near  it  (Fig.  6,  ov^)^  and  the  Fallo- 
pian tube  over  or  near  it.  The  round  ligament  will  generally  be 
somewhat  tense,  and  pass  almost  straight  from  the  abdominal  ring  to 
the  fundus  (Fig.  6,  hrc). 

(2)  The  Bases,  or  Cervical  Portions. 

The  base  of  the  broad  ligament  may  usually  be  directly  palpated 
either  through  the  vagina  or  rectum.  Ordinarily  the  finger  can  feel 
an  indefinite  ridge  on  either  side  of  the  cervix  extending  laterally. 
When  the  base  is  quite  firm  and  resistant,  or  a  little  stretched,  two 
ridges  may  even  be  felt  corresponding  to  the  fibres  running  from  the 
cervix  to  the  anterior  and  to  the  posterior  peritoneal  layers.  When 
drawn  upon  so  as  to  become  unusually  tense  these  two  fibrous  ridges 
are  drawn  into  one  layer,  but  a  much  more  definite  and  prominent 
one.  With  relaxation  of  the  base  of  the  ligament  the  ridge  at  the  side 
of  the  cervix  ceases  to  be  distinctly  felt. 

But  as  palpation  for  any  distance  from  the  cervix  is  occasionally 
rendered  unsatisfactory  by  a  small  vagina  or  the  general  firmness  of 
the  supra-vaginal  tissue,  we  may  find  it  convenient  to  calculate  the 
condition  of  the  base  of  the  broad  ligament  from  the  position  and 
mobility  of  the  cervix  and  ureters.  When  the  cervix  is  down  near 
the  coccyx  or  forward  near  the  vaginal  entrance  the  base  of  the  liga- 
ment, as  already  intimated,  must  be  stretched  or  relaxed.     In  the  first 


VAGINAL    PALPATION^    OF    THE    SACEO-UTERINE    LIGAMENTS.       83 

case,  if  stretched,  it  will  be  easily  felt,  if  relaxed,  it  will  not.  In  the 
second  case  its  lower  edge  will  be  turned  forward  and  upward  and 
will  afford  little  or  no  characteristic  resistance. 

Pressing  the  cervix  from  side  to  side,  the  amount  of  resistance  en- 
countered informs  us  of  the  amount  of  relaxation,  stretching  or 
rigidity  of  this  portion  of  the  ligament.  The  relaxed  ligament  affords 
practically  no  resistance  to  lateral  displacement  of  the  cervix,  and 
allows  the  cervix  to  settle  slowly  back  towards  the  median  line ;  the 
normal  ligament  affords  but  little  resistance,  and  admits  of  a  consid- 
erable displacement,  yet  by  its  elasticity  brings  the  cervix  back  into 
position  immediately  and  rapidly ;  the  stretched  ligament  affords 
considerable  elastic  resistance,  and  admits  of  only  slight  lateral  dis- 
placement ;  while  the  rigid  ligament  allows  of  little  or  no  displace- 
ment without  such  violence  as  to  cause  the  patient  great  discomfort. 

When  the  base  of  the  broad  ligament  is  much  relaxed  the  ureter  is 
no  longer  held  normally  taut,  but  becomes  more  or  less  flabby,  runs  a 
little  nearer  the  pubis,  and  may  be  hooked  forward  near  to  the  anterior 
pelvic  wall.  When  the  base  of  the  ligament  is  turned  forward  and 
upward  as  in  twisting  of  the  whole  ligament  from  a  backward  ver- 
sion of  the  uterus,  the  ureter  may  be  dragged  forward  so  as  to  be 
easily  palpated  against  the  anterior  and  lateral  pelvic  wall.  When 
the  bases  of  both  broad  ligaments  are  relaxed  and  turned  forwards 
the  inter-uretric  ligament  and  the  trigone  are  found  considerably 
nearer  the  pubes  than  otherwise  (see  Fig.  51,  c^). 

With  relaxation  of  the  base  of  only  one  ligament  the  cervix,  when 
it  sinks  down  or  moves  forward,  must,  of  course,  swing  slightly  toward 
the  opposite  side  since  the  normal  ligament  only  allows  the  cervix  to 
swing  upon  its  attachment  to  the  pelvic  wall  as  a  radius.  The  direc- 
tions already  given  for  determining  the  position  of  the  corpus  and 
cervix  uteri  when  laterally  displaced,  will  also  aid  in  the  diagnosis 
of  contraction  and  stretching  of  one  ligament  at  a  time. 

Vaginal  Palpation  of  the  Sacro-uterine  Ligaments. 

Two  fingers  carried  high  up  in  the  posterior  fornix  vaginae  can 
usually  feel  the  semi-circular  folds  of  the  sacro-uterine  ligament  ex- 
tending outward,  backward  and  upward.  If  contracted  they  will 
pass  straight  towards  their  sacral  attachments,  and  form  a  well-defined 
V  whose  angle  is  at  the  cervix.  If  they  cannot  be  thus  reached  the 
cervix  may  be  hooked  forward  by  the  finger  as  represented  in  Fig.  49, 
in  artificial  tension  of  the  round  ligaments,  except  that  the  middle 
finger  is  kept  behind  the  cervix  and  in  the  posterior  fornix,  against 
the  ligaments  (s  u)  stretched  so  as  to  assume  the  V-shape  (see  Fig. 
52,  *).  In  case  the  cervix  be  forward  so  as  to  stretch  them,  and  the 
fundus  turned  back  upon  or  between  them,  they  will  often  be  so 


84  EXAMINATION    OF   THE    FEMALE    PELVIC    OEGANS. 

attenuated,  and  hug  the  sides  of  the  corpus  uteri  so  closely,  as  not  to 
be  felt.  The  finger  may  then,  by  pressing  high  up  in  the  posterior 
fornix,  tilt  the  body  of  the  uterus  forward  and  upward,  and  reach  over 
one  of  the  folds  from  which  the  uterus  has  been  lifted. 

The  position  and  mobility  of  the  cervix  is  sometimes  of  great  value 
in  estimating  the  condition  of  these  ligaments,  since  they  are  some- 
times difficult  to  reach.  When  they  are  retracted  the  upper  part  of 
the  cervix  is  drawn  up  toward  the  second  sacral  vertebra  and  the  os, 
if  no  flexion  exist,  will  be  turned  backward  facing  the  lower  sacral 

Fig.  52. 


uterine  Torsiou  produced  by  Contraction  of  the  Saero-uterine  Ligament  of  one  Side  (1,  2,  3). 
Straightening  of  sacro-uterine  ligament  by  traction  (4)  causing  them  to  assume  a  V-shape  Q/^). 

vertebrae.  The  external  os  may  then  be  from  three  to  three  and  a  half 
inches  from  the  inferior  pubic  ligament  and  more  than  an  inch  above 
the  coccyx  (Fig.  53).  When  the  retraction  is  permanent  the  os  and 
lower  end  of  the  cervix  often  points  forward  more  than  natural,  but 
remains  in  the  back  part  of  the  pelvis. 

The  distance  of  the  cervix  from  the  coccyx  and  inferior  pubic  liga- 
ment is  almost  in  proportion  to  the  amount  of  shortening.  The  fun- 
dus is  at  the  same  time  pressed  downward  by  the  abdominal  pressure 
acting  more  effectively  on  the  upper  longer  arm  of  the  uterine  lever, 
so  that  the  body  is  easily  felt  through  the  anterior  vaginal  wall. 
When  the  contracted  round  ligaments  draw  the  fundus  down  near  the 
symphysis  the  position  of  the  uterus  seems  the  same  to  the  inexperi- 
enced or  hasty  finger ;  but  a  measurement  will  show  that  although 
the  OS  is  turned  backward  the  end  of  the  cervix  is  not  drawn  up  from 
the  coccyx  and  is  but  little  farther  from  the  inferior  pubic  ligament 
than  normal  (see  Fig.  50)  and  the  internal  os  is  drawn  toward  instead 
of  from  the  subpubic  ligament,  as  in  contraction  of  the  sacro-uterine 


VAGINAL    PALPATION    OF   THE   SACEO-UTERINE    LIGAMENTS.       85 


folds  (compare  Figs.  50  and  53).  The  resistance  to  upward  pressure 
by  the  fundus  so  noticeable  in  contraction  of  the  normal  ligaments 
(see  Palpation  of  Round  Ligaments,  p.  69)  will  be  absent  and  the  uterus 
will  have  its  fulcrum  at  the  attachments  of  the  sacro-uterine  ligaments 
(Fig.  49)  instead  of  at  the  fundus.  The  length  and  the  resistance  of 
the  latter  may  also  be  tested  bimanually  by  hooking  the  vaginal  finger 
behind  the  lower  end  of  the  cervix,  and  bringing  the  external  hand 
down  over  and  behind  the  fundus.  By  thus  pulling  the  fundus  and 
cervix  forward  simultaneously,  we  draw  directly  upon  the  ligaments. 

Fig.  53. 


Position  of  Uterus  produced  by  contraction  of  the  Sacro-uterine  Ligaments  (J^). 
Compare  with  Pig.  50.    (Case  118,  office  record  of  1886,  Mrs,  McC). 

When  they  are  normal  or  relaxed  the  vaginal  finger  will  sometimes 
reach  up  between  their  cervical  attachment  so  as  to  pull  the  cervix 
forward  toward  the  symphysis.  In  nullipara  they  lose  little  by  little 
their  distensibility,  and  as  age  advances  become  firm  and  compara- 
tively inelastic. 

The  presence  of  the  external  os  down  near  the  coccyx,  or  forward 
near  the  pubes,  is  proof  of  relaxation  or  stretching  of  their  substance. 
Direct  palpation  behind  and  on  either  side  of  the  cervix  is  then  easy 
and  affords  more  definite  evidence  of  the  condition. 

Contraction  of  only  one  of  the  ligaments  is  attended  by  displace- 
ment of  the  cervix  backward,  upward  and  toward  the  same  side.     In 


86  EXAMIXATIOX    OF    THE    FEMALE    PELTIC   OEGAXS. 

addition  to  tins  the  cervix,  as  B.  S.  Schultze  has  taught  us,*  is  tmsted 
so  that  the  side  toward  the  contraction  is  turned  forward,  i.e.,  the  pos- 
terior surface  of  the  cervix  faces  toward  the  direction  of  the  contraction, 
and  does  so  in  j^roportion  to  the  contraction.  Fig.  52,  ^,  \  ^,  shows 
the  direction  of  the  transverse  slit  of  the  os  with  the  different  degrees 
of  contraction.  The  uterus  if  pressed  in  all  directions  will  be  felt  to 
move  upon  the  contracted  ligament  as  upon  a  pivot,  in  a  manner  that 
is  striking  and  characteristic. 

Palpation  of  the  Pubo-Vesico-Uterine  Ligament. 

The  firm  connective  tissue  union  between  the  bladder  and  vagina, 
and  bladder  and  uterus,  and  the  attachments  of  the  bladder  and  vagina 
to  the  pelvic  fascia  behind  the  pubes,  constituting  the  pubo-vesico- 
uterine  ligament,  form  a  large  and  important  part  of  the  pelvic  roof. 
In  the  dorsal  position  the  finger  on  either  side  of  the  urethra  may  be 
brought  up  without  interference  of  the  soft  parts,  against  the  inferior 
pubic  ligament  and  carried  straight  back  to  the  cer^-ix,  along  the  an- 
terior vaginal  wall  a  distance  of  about  two  and  a  half  inches. 

With  the  cervix  at  or  in  front  of  its  normal  position  a  want  of  retrac- 
tility is  generally  revealed  by  a  transverse  fold  extending  across  under 
the  base  of  the  trigone,  and  along  the  course  of  the  ureters,  forming  a 
crescent  whose  convexity  is  forward.  If  the  relaxation  be  in  the 
parametrium  the  anterior  vaginal  wall  will  be  flat  and  firm  under  the 
trigone,  but  there  will  be  a  furrow  around  the  cer\dx.  The  relaxation 
is  then  due  to  the  forward  position  of  the  cervix,  especially  its  lower 
portion,  and  is  due  to  the  altered  axis  of  the  uterus.  An  unusual  dis- 
tance of  the  base  of  the  trigone  and  inferior  ends  of  the  ureters  from 
the  cervix  would  be  diagnostic  of  true  relaxation  or  lengthening  of  the 
parametric  end.  If  the  relaxation  be  in  the  peripheral  portion  the  fold 
will  consist  more  of  a  depression  about  the  trigone  and  urethra  and 
pubic  arch  instead  of  a  raising  of  the  parametrium.  An  unusual 
flabbiness  is  also  found  in  the  latter  class  of  cases,  permitting  the 
fino-er  to  press  high  up  behind  the  pubes  before  encountering  much 
resistance.  Temporary  vaginal  folds  are  produced  by  the  emptying 
of  an  overfilled  bladder,  changes  in  the  position  of  the  body,  etc., 
chiefly  by  their  effect  upon  the  jDosition  of  the  cervix. 

When  the  cervix  is  much  farther  back  than  normal  the  pubo-uterine 
ligament  must  be  either  stretched  or  relaxed.  If  stretched  it  will  be 
flat,  firm  and  smooth  ;  if  relaxed  it  will  be  soft  and  somewhat  convex. 
The  base  of  the  trigone  will  indicate  by  its  increased  distance  from  the 
cervix,  the  pubes,  or  both  whether  the  stretching  or  relaxation  be  in 
the  peripheral  or  deeper  portion  of  the  whole  ligament. 

*  Die  Pathologie  und  Therapie  der  Lageveraenderungea  der  Gebaermutter.  Berlin, 

1881. 


PALPATION    OF    THE    PUBO-VESICO-UTEEINE    LIGAMENT.  87 

When  the  ligament  is  overclistended  or  displaced  downward  by 
pressure  or  by  a  loss  of  integrity,  it  becomes  convex  instead  of  flat  to 
the  touch.  If  the  parametric  portion  alone  be  distended  and  bulging 
down,  we  will  notice  an  increase  in  the  distance  from  the  vaginal  por- 
tion of  the  cervix  to  the  trigone  and  to  the  pubes,  and  be  obliged  to 
press  deep  into  the  parametrium  before  reaching  the  upper  end  of  the 
cervix.  The  convexity  commences  at  the  cervix.  Distension  of  the 
parametric  portion  to  an  extreme  degree,  accompanied  by  a  separation 
of  the  cervix  and  bladder,  is  recognized  bj^  the  pressure  of  intestinal 
loops,  and  borborygmus,  over  the  upper  bulging  end  of  the  anterior 
vaginal  wall  beyond  the  base  of  the  trigone  and  between  the  ureters. 
Pressure  high  up  in  the  lateral  fornices,  or  a  bimanual  examination, 
shows  the  whole  uterus  to  be  pressed  back  behind  the  pelvic  axis.  The 
prolapsed  parts  may  be  felt  at  the  vaginal  entrance  when  standing,  yet 
can  be  made  to  sink  back  deep  into  the  vagina  when  the  dorsal  de- 
cubitus is  assumed.  In  such  case  the  lower  end  of  the  ureters,  base  of 
the  trigone,  bladder,  and  the  upper  end  of  the  urethra  are  displaced 
forward  toward  the  symphysis  but  not  much  downward. 

If,  however,  the  anterior  or  peripheral  end  of  the  ligament  be  relaxed 
or  injured  so  as  to  be  displaced  downward,  the  last-mentioned  struct- 
ures will  swing  around  under  the  pubic  arch  into  the  vaginal  entrance. 
Intestinal  borborygmus  or  resonance  will  not  be  felt  as  the  bladder 
must  come  down  in  front  of  the  bowel,  nor  can  the  prolapsed  parts 
readily  sink  back  deep  into  the  vagina.  There  will  also  be  a  short 
stretch  of  firm  parametric  tissue  (flat  or  concave)  in  front  of  the  cervix, 
through  which  the  upper  end  of  the  cervix  can  be  felt. 

If  the  displacement  and  relaxation  involve  the  whole  pubo-uterine 
ligament  the  urethra,  trigone,  bladder  and  parametric  portion  will  all 
be  felt  to  be  bulging  down  together  from  the  cervix  to  the  pubic  arch. 

If  the  chief  relaxation  and  displacement  be  laterally  in  the  i)ara- 
vesical  region  the  anterior  vaginal  grooves  (or  sulci)  instead  of  being 
elevated  as  high  or  higher  than  the  centre  of  the  anterior  vaginal  wall 
will  be  depressed  and  rounded  off,  apjDarently  narrowing  the  wall. 

Contraction  of  the  pubo-uterine  ligament  draws  the  cervix  forward, 
and  renders  the  anterior  vaginal  wall  firm  and  rough.  It  sometimes 
makes  the  anterior  lip  of  the  cervix  seem  shorter  than  natural,  and 
may  produce  a  distinct  fraenum  extending  from  the  anterior  lip  into 
the  vaginal  wall,  not  unlike  that  felt  in  front  of  the  atrophied  senile 
cervix.  (See  Senile  Cervix,  p.  60.)  If  the  cervix  be  turned  forward 
by  the  displaced  fundus  the  ligament  may  be  flabby  to  the  touch,  and 
will  only  develop  the  above  qualities  when  an  attempt  at  replacement 
is  made.  The  replacement  of  the  cervix  accompanied  by  palpation 
of  the  base  of  the  trigone  will  show  by  its  position  whether  one  end 
only,  or  the  whole  ligament,  is  contracted. 

Contraction  laterally  in  the  para-vesical  region  is  apt  to  be  unilateral, 


88  EXAMIXATION    OF    THE    FEMALE    PELVIC    OEGAXS. 

and  draws  the  vaginal  groove  or  sulcus  upward  and  outward,  making 
it  deeper  and  narrower,  and  unless  the  cervix  be  also  drawn  to  the 
same  side,  gives  it  a  curve  whose  concavity  is  inward.  This  is  easily- 
recognized  by  the  finger  tip  in  passing  from  the  urethral  notch  to  the 

lateral  fornix. 

Palpation  of  the  Vagina. 

During  vaginal  palpation  of  the  pelvic  organs  it  is  necessary  to  take 
into  consideration  the  natural  characteristics  and  varying  conditions 
of  the  vagina  itself.  In  the  parous  woman  the  vagina  is  often  suffi- 
ciently voluminous  and  relaxed  to  offer  no  obstacle  to  the  explora- 
tion of  the  whole  pelvic  interior,  while  in  the  nulliparous  or  ^drgin 
state  it  sometimes  lies  close  around  the  finger  like  an  elastic  tube,  pre- 
venting the  recognition  of  anything  except  the  cervix  uteri.  Thus 
we  have  a  vaginal  resistance  or  elasticity  to  be  diiferentiated  and  sub- 
tracted from  that  of  the  other  tissues,  and  which  gives  rise  to  different 
sensations  according  to  the  distance  of  the  tissues,  and  the  amount  of 
force  used  in  reaching  and  palpating  them. 

Although  the  character  of  vaginal  resistance  is  usuall,y  of  a  slightly 
elastic  nature,  sometimes  the  vaginal  walls  act  as  an  inelastic  bag-like 
check  to  the  progress  of  the  finger,  which  vaaj  be  compared  to  the  check 
experienced  by  the  extended  fingers  in  putting  on  a  short,  loose  mitten. 
This  check  may  be  so  sudden  or  complete,  especially  to  lateral  upward 
pressure  into  the  anterior  vaginal  grooves,  as  to  lead  to  the  belief  of 
having  encountered  a  boggy  tumor.  Continuous  steady  pressure  in 
such  cases  gradually  draws  the  vagina  toward  the  part  to  be  exam- 
ined, overcomes  the  interference,  and  gives  time  and  opportunity  to 
detect  the  characteristic  sensations  afforded  by  contact  with  each  tissue 
as  it  is  reached.  (Resistance  of  the  submucous  or  supravaginal  tissues 
has  other  characteristics,  viz.,  that  of  a  stretched  cord  or  band,  as  an 
ureter,  an  artery,  a  cicatrix,  a  round  or  ovarian  ligament;  of  a  flat  or 
convex  surface,  as  the  body  of  the  uterus,  base  of  a  broad  ligament, 
pjelvic  wall,  the  trigone,  levator  ani  muscle,  etc. ;  of  a  lump  or  ridge, 
as  the  ovary,  rectum,  a  fecal  mass,  a  contracted  muscle,  the  uterus, 
etc. ;  or  of  a  varying  character,  as  when  passing  from  the  peripheral 
connective  tissue  into  the  parametrium,  from  the  flat  pubo-uterine 
ligament  to  the  tissue  upon  the  side,  or  from  the  base  of  the  broad 
ligament  under  the  sacral  peritoneal  pouches,  etc.) 

Resistance  in  the  fornices,  except  in  a  very  short  vagina,  depends 
upon  the  firmness  of  the  overlying  connective  tissue  to  which  it  is 
intimately  attached,  and  affords  some  knowledge  of  the  firmness  or 
tension  of  the  ligaments  inserted  over -and  into  them.  To  the  gentle 
touch,  they  should  feel  smooth  and  firm.  As  the  finger  glides  forward 
from  the  anterior  fornix,  the  anterior  vaginal  wall  feels  smooth,  flat 
and  elastic  for  about  an  inch.     Here  in  passing  from  the  soft  elastic 


PALPATIO?^   OF   THE   VAGINA.  89 

parametrium  across  the  inter-uretric  ligament  and  under  the  trigone,  a 
sensation  of  increased  firmness  and  roughness  is  experienced.  Towards 
the  pubes  this  roughness  is  developed  into  distinct  transverse  rugae 
which  cover  the  urethra  to  the  meatus.  Frequently  one  or  two  rugee 
extend  under  the  inferior  pubic  ligament  across  the  urethral  notches 
where  the  mucous  membrane  is  closely  adherent.  At  the  centre  of  the 
urethral  fossae  and  back  along  the  anterior  vaginal  grooves,  or  lateral 
edges  of  the  pubo-uterine  ligament,  to  the  lateral  fornices,  the  mucous 
membrane  becomes  smooth  and  concave  to  the  touch. 

These  rugae  are  caused  by  the  contraction  or  retraction  of  the  fibrous 
tissue  of  the  vaginal  wall,  and  render  it  practically  shorter,  thicker 
and  firmer,  without  destroying  its  distensibility.  When  the  nuUipa- 
rous  cervix  has  been  displaced  forward  for  a  long  time  the  rugse  become 
large  and  firmer,  shortening  and  straightening  the  vaginal  wall  and 
taking  the  place  of  the  transverse  fold  that  results  from  such  tempo- 
rary displacement.  Such  shortening  finally  may  prevent  replacement 
of  the  cervix,  and  is  generally  an  evidence  of  a  long  continuance  of 
the  malposition.  We  may  distinguish  physiological  retraction  from 
atrophy  or  pathological  contraction  by  practicing  long-continued  mod- 
erate pressure  upon  the  cervix.  In  the  first  condition  the  cervix  will 
draw  out  the  vaginal  wall  and  go  back  to  place,  in  the  second  it  will 
not.     In  case  of  atrophy  the  rugse  are  either  small  or  absent. 

Pathological  changes  are  apt  to  be  accompanied  b}^  more  hardening 
of  the  deeper  tissues  and  to  be  more  pronounced  upon  one  side,  or  over 
a  more  limited  area,  or  along  a  ridge.  Contraction  of  the  anterior 
vaginal  wall  tends  to  bring  forward  the  centre  of  the  projecting  trans- 
verse crescentic  fold  found  in  forward  displacements  of  the  cervix, 
until  its  posterior  or  concave  edge  is  at  or  in  front  of  the  base  of  the 
trigone,  and  thus  increases  the  curve,  while  contraction  of  only  the 
deeper  connective  tissue  draws  the  side  as  well  as  the  centre  forward, 
and  tends  to  place  the  ureters  in  or  over  the  fold  instead  of  at  the  pos- 
terior edge.  Contraction  of  the  anterior  vaginal  wall  is  also  known 
by  unusual  difficulty  in  detecting  the  trigone  and  ureters  through 
its  hard,  rough,  thickened  substance.  Infiltration  may  cause  the 
same  difficulty,  but  will  be  known  by  the  smooth,  soft,  and  only 
slightly  elastic,  or  doughy  feel  of  the  mucous  membrane.  Extreme  or 
long-standing  contraction  of  the  vaginal  wall  is  also  accompanied  by 
an  extension  of  the  rugse  backward  to  the  cervix  and  laterally  into  the 
anterior  grooves  and  urethral  fossae  so  as  to  narrow  them,  while  a  con- 
traction of  only  the  connective  tissue  separates  and  elevates  the  grooves, 
and  slightly  increases  their  areas  of  smooth  mucous  membrane. 

The  main  signs  of  a  relaxation  of  the  anterior  vaginal  wall  are 
smoothness  and  flabbiness  of  the  mucous  membrane  without  much 
change  in  the  deeper  tissues.  When  such  relaxation  occurs  indepen- 
dent of  the  deeper  tissues  it  is  usually  inferiorly  about  the  urethra 


90  EXAMINATIOX    OF   THE    FEMALE   PELVIC    ORGANS. 

and  is  known  Idj  an  increased  area  of  smoothness  or  flabbiness  about 
the  urethral  fossse  and  notches.  An  extensive  loosening  of  the  relaxed 
vagina  from  the  pubic  connective  tissue  attachments  is  recognized  by 
a  widening  and  depression,  or  obliteration,  of  the  urethral  fossse,  and 
a  separation  of  the  mucous  membrane  from  its  hard  base  at  the  notches, 
under  the  sub-pubic  ligament,  and  a  descent  of  the  urethra  under 
the  pubic  arch,  with  the  apex  of  the  trigone,  the  neck  of  the  bladder. 
The  inter-uretric  ligaments  are  felt  behind  and  near,  but  not  below, 
the  pubis. 

The  posterior  and  lateral  vaginal  walls  at  the  upper  end  of  the  va- 
gina feel  soft  and  displaceable  in  the  pelvic  chamber  about  it,  and 
only  present  firm  resistance  to  deep  pressure.  Toward  the  introitus 
they  become  rugate  and  closely  attached  to  the  recto-vesical  fascia, 
over  the  levator  ani  et  vaginae  muscles,  on  either  side  of  the  rectum. 
As  upon  the  anterior  wall,  so  here  the  rugse  and  closeness  of  attach- 
ment to  the  fascia  at  the  introitus  indicate  the  amount  of  contraction 
of  the  wall,  and  the  condition  of  its  underlying  connective  tissue. 
Deeper  within  the  vagina  the  posterior  wall  may  be  held  so  high  by 
the  contractility  of  the  structures  that  all  characteristic  resistance  of 
underlying  structures  will  be  lost,  as  we  frequently  find  in  old  nulli- 
para, and  imperfectly  developed  young  women.  Or  the  tissues  may 
be  relaxed  here  as  elsewhere  and  allow  the  finger  to  lie  flat  upon  the 
pelvic  floor. 

The  rectal  notches  become  deeper  from  relaxation  of  the  vaginal 
entrance,  for  the  mucous  membrane  is  then  no  longer  held  up  from  the 
rectum.  The  posterior  vaginal  grooves,  which  are  short  in  the  virgin 
vagina  and  are  soon  lost  to  the  touch  in  the  elastic  vaginal  tube,  become 
larger,  deeper  and  more  noticeable  as  the  relaxed  vagina  allow^s  the 
posterior  wall  to  sink  to  the  pelvic  floor  on  either  side  of  the  rectum. 
Firm  contraction,  on  the  contrary,  may  render  the  posterior  grooves 
so  shallow  as  to  be  imperceptible  to  the  finger. 

A  softness,  smoothness  and  puffiness  of  the  posterior  wall,  forming  a 
loose  transverse  fold  at  the  introitus  into  which  the  examining  finger  is 
apt  to  catch,  indicates  a  relaxation  of  the  Avail  and  a  loosening  from 
its  connective  tissue  attachments  to  the  rectum  and  pelvic  floor.  The 
posterior  vaginal  grooves  and  rectal  notches  then  become  either  lost 
in  the  folds  or  displaced  by  being  loosened  from  their  base.  In  ex- 
treme cases  the  vaginal  wall  protrudes  externall}-.  The  finger  slipped 
into  the  rectum  can  easily  ascertain  if  the  whole  recto-vaginal  septum 
is  prolapsed,  as  in  that  case  the  anterior  rectal  wall  is  felt  to  pass  into 
the  mass. 

Rectal  Examination  of  the  Pelvic  Roof. 

In  cases  of  small,  or  contracted  vaginae,  imperforate  hymen,  displaced 
pelvic  viscera,  or  diseases  in  the  back  part  of  the  pelvis,  it  not  unfre- 


METHOD    OF   RECTAL   INDAGATION. 


91 


quently  becomes  desirable  or  necessary  to  examine  through  the  rectum. 
The  advantage  of  such  examination  lies  not  only  in  the  frequent  un- 
fitness of  the  vagina,  but  in  the  shortness  and  directness  of  the  route 
to  the  posterior  superior  parts  of  the  pelvic  cavity. 

Rectal  indagation  may  be  practised  with  one  or  two  fingers  or  the 
half  hand.  The  latter  method  usually  requires  either  local  or  general 
anaesthesia.  The  introduction  of  the  whole  hand,  as  is  often  recom- 
mended, has  been  known  to  permanently  impair  the  tonicity  of  the 
sphincters,  and  should  not  be  resorted  to  unless  the  hand  be  small, 
the  anus  and  rectum  easily  dilatable,  and  an  accurate  diagnosis  be 
imperative  and  unattainable  by  milder  measures. 

Method  of  Rectal  Indagation. 
As  the  rectal  mucous  membrane  is  sensitive,  comparatively  dry,  and 
collapsed  into  soft  folds,  the  examining  finger  should  be  abundantly 
lubricated  with  an  absolutely  unirritating  ointment,  and  introduced 

riG  54 


MaLwJ  of  L.trv.JuCx.,g  tL^  1  ...ger  wxt^  tl...  Lactam  (i). 
/I.  Touching  internal  sphincter  ani  and  lower  edge  of  perineal  septum ;  J-,  finger  passed  through 
the  interior  sphincter  under  the  pelvic  floor  edge ;  f^,  finger  turned  back  over  pelvic  floor  edge 
for  the  examination  of  the  pelvic  interior. 

slowly  with  the  palmar  surface  forward  or  to  one  side.  The  sphincter 
ani  dilating  toward  the  perineal  body  allows  the  finger  to  come  in 
contact  Avith  the  lower  edge  of  the  perineal  septum  where  the  rectal 
wall  containing  the  second  sphincter  is  attached  (Fig.,  81  is,  also  34,  s), 
and  from  which  it  can  be  traced  around  the  anus,  a  trifle  farther  from 
the  external  anal  orifice  behind  than  in  front.  Introduced  straight 
upward  in  the  axis  of  the  body,  the  finger  comes  squarely  against  the 
posterior  rectal  wall  which  here  passes  almost  directly  forward  under 
the  pelvic  floor  from  the  anus  to  the  rectal  promontory  or  pelvic  floor 


92  EXAMINATION   OF   THE    FEMALE    PELVIC    OEGANS. 

edge.  If  the  finger  be  directed  slightly  forward  (Fig.  54,/^  and/^)  the 
edge  of  the  fibres  of  the  levator  ani  at  the  promontory,  which  are 
normally  relaxed  and  offer  but  little  resistance,  may  be  felt  and  pressed 
back  out  of  the  way  (Fig.  54,/^).  Should,  however,  much  irritation 
exist,  or  be  ]3roduced  by  rough  fingering,  the  levator  ani  may  con- 
tract and  lift  up  the  folded  rectum  against  the  posterior  vaginal  wall 
(Fig.  21)  and  effectually  resist  the  unwarranted  or  awkward  intrusion. 

The  levator  ani,  holding  the  collapsed  and  closed  rectum  loosely 
forward,  not  only  forms  a  boundary  below  which  faeces  never  lodge, 
but  has  the  power  of  firm  voluntary  contraction,  and  may,  under 
pathological  influences,  contract  so  tightly  and  continuously  as  to 
interfere  with  the  circulation  and  enervation  of  the  parts  passing 
through  the  pelvic  floor  outlet.  Hence  it  would  be  in  accordance 
with  its  function  to  call  the  anterior  portion  of  the  levator  ani  (the 
levator  ani  proper)  the  rectal  sphincter  or  third  sphincter  of  the  bowel. 
(See  Fig.  17).     It  is  in  reality  the  sphincter  of  the  pelvic  outlet. 

The  finger  as  it  enters  the  anus  should  therefore  be  gently  directed 
forward  along  the  perineal  body  (see  Palpation  of  the  Perineum)  until 
the  recto-vaginal  septum  is  reached.  Then  by  turning  the  finger  end 
so  as  to  make  the  perineal  body  recede  upward  and  the  pelvic  floor 
edge  backward  the  road  becomes  straight  (Fig.  54,  /^). 

When  the  palmar  surface  is  turned  forward  the  finger,  almost  as 
soon  as  it  has  penetrated  beyond  the  pelvic  floor  edge  into  the  inner 
pelvic  or  subperitoneal  connective-tissue  chamber  (see  page  68),  usually 
encounters  the  cervix  which,  being  nearer  the  anus  than  the  vulva, 
seems  to  the  inexperienced  touch  too  far  forward,  and,  being  covered 
by  both  a  rectal  and  vaginal  wall  and  a  little  intervening  connective 
tissue,  too  large. 

If  any  doubt  exists  as  to  what  is  thus  felt,  a  finger  of  the  other  hand, 
or  a  thumb  of  the  same  hand,  may  be  slipped  into  the  vagina  to  the 
cervix  and  serve  as  an  indicator.  When  the  cervix  is  far  back  and 
the  fundus  uteri  turned  down  over  the  vesico-vaginal  septum  the 
corpus  is  felt  as  if  it  lay  upon  the  elevated  anterior  rectal  wall.  When 
the  cervix  is  forward  and  the  fundus  turned  back  the  finger  end  passes 
under  and  back  of  the  cervix,  instead  of  in  front,  and  reaches  under 
the  corpus  more  readily  than  per  vaginam. 

Although  we  may  reach  the  smaller  structures  of  the  anterior  half 
of  the  pelvic  roof,  such  as  the  lower  end  of  the  ureters,  round  ligament, 
etc.,  in  somewhat  the  same  manner  as  through  the  vagina,  they  are 
obscured  by  more  intervening  connective  tissue,  and  the  resistance  of 
the  rectal  walls.  Hence,  unless  the  vagina  be  closed  or  contracted, 
and  the  rectum  quite  lax  we  need  not  attempt  such  an  exploration, 
but  pass  the  finger  on  to  the  side  of  the  cervix  and  hook  it  under  the 
base  of  a  broad  ligament.  This  will  be  usually  felt  as  a  firm,  well- 
defined  band  stretching  to  the  side  of  the  pelvis.  In  many  cases  the 
posterior  peritoneal  layer  extending  under  and  forming  the   sacral 


DIGITAL,    EXPLOEATIOIS"   THROUGH   THE    UPPER   RECTUM.         93 

peritoneal  pouch  feels  firm  and  is  traceable  back  to  where  it  is  reflected 
up  to  form  the  sacro-uterine  fold.  The  finger  passed  back  under  the 
pouch  will,  if  the  rectum  be  voluminous  and  lax,  readily  glide  up  into 
the  Douglas  pouch,  and  may  be  hooked  over  one  of  them.  If  the  body 
of  the  uterus  be  turned  back  upon  the  recto-uterine  peritoneal  folds  it 
may  be  pushed  up  from  them.  If  the  uterine  appendices  be  in  the 
pouch,  they  will  be  above  and  in  front  of  the  finger,  instead  of  above  and 
behind  it,  as  in  the  vaginal  examination,  and  can  be  palpated  against 
the  posterior  wall  of  the  cervix  in  front,  instead  of  against  the  rectum 
behind ;  or,  if  the  fundus  be  turned  back,  they  will  be  felt  against  the 
corpus  uteri  over  and  in  front  of  the  finger,  instead  of  over  and  behind. 
Sometimes  masses  of  fasces  in  the  upper  rectum  may  be  felt  pressing 
down  behind  and  over  the  uterus,  but  separated  from  the  finger  by  a 
rectal  fold  caused  by  the  contracted  fourth  (called  the  third)  sphincter, 
so  as  to  feel  something  like  the  appendices,  or  some  foreign  substance, 
in  the  sacro-uterine  pouch.  Beside  the  possibility  of  mashing  and 
working  down  such  substance,  there  is  always  the  possibility  of  getting 
beyond  the  rectal  fold  or  constriction  and  in  direct  contact  with  it. 

In  all  these  manipulations  the  rectal  mucous  membrane  should  feel 
soft  and  folded  and  freely  movable  upon  the  finger.  Any  alterations 
of  its  walls  such  as  hardening,  cicatrization,  immobility,  narrowing, 
inelasticity,  unnatural  heat,  sensitiveness,  and  granular,  hemorrhoidal 
or  polypoid  growths,  etc.,  should  be  noticed,  since  they  often  have  a 
material  influence  upon  the  condition  of  the  sexual  organs  and  upon 
the  interpretation  of  the  vaginal  examination. 

If  the  connective  tissue  about  the  sacral  peritoneal  pouches  be  soft, 
ovaries  or  tubes  lying  low  in  them  may  be  felt,  and,  if  at  the  same 
time  the  abdominal  walls  be  lax  and  depressible,  almost  the  whole  of 
the  posterior  half  of  the  pelvis  may  be  examined  bimanually.  In 
those  who  have  borne  many  children  this  may  frequently  be  accom- 
plished, in  old  nullipara  very  seldom. 

Digital  Exploration  through  the  Upper  Rectum. 

As  both  the  sacro-uterine  ligaments  and  fourth  sphincter,  usually 
called  the  third  (Figs.  34  and  35,  D  and  D'-),  are  sometimes  contracted 
and  present  openings  of  almost  the  same  size,  it  is  necessary,  that  the 
finger  may  not  get  lost  in  the  rectal  folds,  to  be  able  not  only  to  find 
the  rectal  sphincter,  but  to  know  it  from  the  ligament.  It  must,  there- 
fore, be  borne  in  mind  that  the  contracted  sacro-uterine  ligaments 
have  an  oval  or  semicircular  aperture  against  or  inseparable  from 
the  cervix,  and  may  be  felt  to  pass  upward  toward  the  second  sacral 
vertebra,  while  the  contracted  fourth  sphincter  is  circular,  separated 
or  separable  by  a  stretch  of  rectal  wall  from  the  cervix,  and  is  against 
or  near  the  lower  end  of  the  sacrum  ;  also  that  the  ligaments  are  not, 
like  the  sphincter,  completely  enveloped  in  puckered  mucous  mem- 


94 


EXAMINATION    OF   THE    FEMALE    PELVIC    OEGANS. 


brane,  inseparable  from  it,  and  dilatable  by  traction  upon  it.  Hence, 
instead  of  pushing  the  rectal  wall  up  behind  the  cervix,  we  must 
direct  the  finger  back  toward  the  sacrum  until  it  enters  the  sphincter. 
If  the  latter  be  closed,  forward  traction  upon  the  rectal  wall  will 
usually  dilate  it  sufficiently  for  the  finger  to  enter  it  and  pull  it  open 
in  the  direction  of  the  cervix,  and  thus  open  up  a  direct  route  between 
the  sacro-uterine  folds  to  the  sacral  promontory  out  upon  the  pelvic 
roof.     Two  fingers  of  the  right  hand  are  best  for  such  an  examination. 

Fig.  55. 


--:-.-,-.,///#'>'^'%*////*/A'-^>«^^^ 


W//.>///,//:->'^y.'//y^ 


Bimanual  Examination  of  the  Posterior  Surface  of  the  Uterus  and  the  Posterior  Pelvic 
Spaces  from  the  Rectum.    (After  a  case  of  Hematoma.) 

If,  while  we  press  well  up  behind  the  uterus  with  the  rectal  fingers, 
we  bring  the  fingers  of  the  other  hand  down  behind  the  fundus  from 
the  surface  of  the  abdomen,  we  may  approximate  them  behind  the 
uterus.  When  the  parts  are  relaxed  and  not  irritable,  this  can  occa- 
sionally be  done  with  one  finger  in  the  vagina,  and  without  an  an- 
esthetic. Fig.  55  represents  such  an  examination  made  with  one 
finger  in  the  rectum  without  an  anjcsthetic,  in  a  case  of  hematoma 
extending  from  one  broad  ligament  across  the  posterior  wall  of  the 


CIRCUMDIGITATION    OF   THE    UTERUS,    ETC. 


95 


uterus  into  the  other.  The  broad  ligaments  can  be  examined  at  the 
same  time  in  the  same  way,  and  the  changes  which  occur  be  quite 
accurately  estimated.  With  two  fingers  higher  in  the  rectum,  and  the 
patient  anaesthetized,  the  uterus  is  not  pulled  so  far  forward  as  repre- 
sented in  Fig.  55. 

In  all  central  and  posterior  positions  of  the  ovaries  they  are  found 
within  easy  reach  of  the  fingers  passed  into  the  upper  rectum.  The 
fingers  seem  right  among  and  against  the  ovaries,  tubes,  ligaments, 
arteries,  small  intestines,  etc.,  and  can,  with  a  little  experience,  map 
them  upon  the  mind.  Indeed,  when  thus  carefully  and  intelligently 
examined,  the  pelvis  has  no  secret  places,  except  those  of  a  micro- 
scopic kind. 

The  Recto-  Vaginal  Chrip. 

When  the  fundus  is  turned  into  the  hollow  of  the  sacrum  the 
uterus  may  usually  be  firmly  grasped  between  the  forefinger  in  the 


Fig.  56. 


Kecto-Vaginal  Grip  of  the  Retroverted  Uterus  {}4). 

rectum  behind  the  fundus  and  the  thumb  in  the  vagina  in  front  of 
the  cervix,  and  its  flexibility,  mobilit}^,  and  sensitiveness  accurately 
and  satisfactorily  determined  (Fig.  56}. 

Circumdigitation  of  the  Uterus  from  the  Abdomen,  Vagina,  and  Rectum. 

A  combination  of  these  different  methods  of  examination  is  useful 
in  some  cases.  By  introducing  one  or  two  fingers  into  the  rectum 
and  behind  the  cervix,  the  thumb  of  the  same  hand  into  the  vagina 
in  front  of  the  cervix,  the  thumb  of  the  other  hand  against  the  de- 
pressed abdominal  wall  below  the  fundus,  and  the  fingers  similarly 


96  EXAMIXATIOX    OF    THE    FEMALE    PELVIC   OEGAXS. 

over  the  fundus,  the  uterus  can  be  grasped  simultaneously  by  the 
fundus  and  cervix  in  a  firm  double  grip,  as  represented  in  Fig.  57. 


Fig.  57. 


Bimanual  Circumdigitation  from  the  Rectum  and  Vagina,  by  means  of  the  Abdominal 
and  Recto- Vaginal,  or  double,  Grip. 

Thus  not  only  the  size  and  shape  of  the  organ  can  be  estimated,  but 
also  its  hardness,  flexibility,  and  mobility.  The  ovaries  may,  during 
ansesthesia,  be  similarly  grasped. 

Palpation  of  the  Interior  of  the  Bladder. 

When  abnormal  or  pathological  conditions  interfere  with  ordinary 
methods,  it  may  become  necessary  to  introduce  the  finger  into  the 
bladder  to  ascertain  the  condition  of  its  mucous  membrane,  or  to  reach 
the  anterior  part  of  the  pelvic  cavity.  The  urethra  should  be  dilated 
first  with  sounds  or  dilators  (see  "  Use  of  the  Urethral  Speculum," 
chap.  IV.)  and  the  little  finger.  After  the  little  finger,  the  index  may 
be  gradually  forced  into  the  bladder.  About  an  inch  back  of  the 
vesical  sphincter  and  about  an  inch  apart  will  be  felt  the  slightly 
elevated  mouths  of  the  ureters  (see  Fig.  58).  The  thumb  of  the  same 
hand,  or  a  finger  of  the  other,  introduced  in  the  vagina  can,  by  locat- 


PALPATION    OF    THE    INTERIOR    OF   THE    BLADDER. 


97 


ing  the  ureters  in  the  vagina  and  passing  up  the  vesico-vaginal  septum, 
sometimes  aid  the  index  in  the  bladder.  The  bladder  being  high  up 
in  the  pelvis  gives  access  to  the  vesico-uterine  tissue  and  pelvic  brim 
better  than  does  the  vagina.    But  the  skill  required  to  palpate  through 


Fig.  58. 


IbBW 


TtL 


ion  of  Uretral  Orifices  (after  Wlnckel). 


the  constricting  urethra,  the  violence  necessarily  done  to  the  i3arts, 
and  the  rarity  of  the  occasions  demanding  such  an  examination  must 
make  it  possible  for  but  few  to  derive  much  benefit  from  it. 

For  the  palpation  of  the  vessels  and  nerves  of  the  pelvic  roof  see  "Palpation  of  the 
Arteries  of  the  Pelvis,"  Chapter  III.  p.  104,  and  the  following  paragraphs. 


CHAPTER    III 


EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS  {Continued). 

The  Pelvic  Floor  and  Perineum. 
As  a  rule  the  pelvic  floor  of  the  child  bearing  woman  may  be  suffi- 
ciently examined  from  the  vagina.  When,  however,  the  vagina  does 
not  permit  of  as  satisfactory  an  exploration  as  is  desirable,  rectal 
indagation  may  become  necessary.  Hence,  we  will  take  up  each  in 
turn,  first  the  vaginal,  then  the  rectal. 

Vaginal  Palpation  of  the  Pelvic  Floor. 
The  Coccyx. — One  or  two  fingers,  introduced  to  the  cervix  uteri  as  a 
starting-point,  may  commence  the  palpation  of  the  pelvic  floor  by 
pressing  downw^ard  and  backward  in  the  median  line  until  the  knotty 


Fig.  59. 


Grasping  the  Coccyx  between  the  thumb  externally  and  the  index  in  the  vagina.    The 
rectum  is  pushed  to  one  side. 

ridge  of  bone  corresponding  to  tlie  anterior  surface  of  the  coccyx  is 
reached.  The  rectum,  if  in  the  way,  should  be  pushed  to  one  side, 
usually  to  the  left.  By  bringing  the  finger  forward  along  the  ridge  to 
the  point  where  it  glides  over  upon  softer  tissue  the  end  of  the  bone 
will  be  distinctly  recognized.     In  a  young  or  poorly  developed  nulli- 


THE   PYEIFORMIS.  99 

par,  and  in  one  who  has  recently  borne  children,  the  tip  of  the  coccyx 
is  depressible  and  elastic.  In  the  fully  developed  nullipar  and  in  the 
aged  this  mobility  diminishes  year  by  year  and  is  sometimes  imper- 
ceptible. A  rigidity  or  temporary  contraction  of  the  levator  ani,  by 
raising  and  hardening  the  pelvic  floor,  makes  the  recognition  of  the 
tip  of  the  bone  quite  difficult  unless  firm  pressure  be  used. 

When  a  more  definite  knowledge  of  the  size,  mobility  and  position 
of  the  coccyx  is  desired,  the  thumb  should  be  brought  externally 
against  the  coccyx,  an  inch  or  a  little  further  back  of  the  anus,  so  that 
the  bone  comes  between  the  index  finger  in  the  vagina,  and  the  thumb 
on  the  integument  externally,  as  represented  in  Fig.  59.  Unless  the 
patient  be  very  fleshy  and  the  perineum  very  rigid  the  bone  will  be 
grasped  without  difiiculty. 

The  presence  of  rigidity,  ankylosis,  displacement,  tenderness,  hyper- 
sesthesia,  etc.,  of  the  coccyx  can  thus  be  definitely  ascertained.  In 
the  young  and  the  parous  woman  the  tip  of  the  bone  may  be  moved 
forward  and  backward  like  a  piece  of  soft  whalebone ;  in  nuUiparous 
middle  age,  and  in  old  age  in  general,  it  may  be  moved  but  little  and 
only  by  considerable  pressure.  If  there  be  immobility  due  to  contrac- 
tion of  the  muscles  of  the  pelvic  floor,  their  resistance  may  be  overcome 
by  firm  pressure,  or  relaxation  may  be  brought  about  by  changing  the 
position  of  the  j^atient. 

The  Small  Sacro- Sciatic  Ligament^  and  Ischial  Spine. 

By  passing  the  finger  back  on  either  side  of  the  rectum  the  small 
sacro-sciatic  ligament  is  felt  running  from  the  lower  end  of  the  sacrum 
and  upper  end  of  the  coccyx  to  the  ischial  spine.  When  the  pelvic 
floor  is  relaxed  the  flnger  immediately  recognizes  it,  for  its  anterior 
edge  is  raised  and  hard  as  compared  with  the  softer  muscles  in  front. 
When  the  pelvic  floor  is  contracted  the  posterior  edge  of  the  ligament 
is  the  only  part  of  it  to  attract  attention  as  the  finger  passes  over  it  into 
the  great  sciatic  foramen.  The  ischial  spine  is  felt,  at  the  converging 
outer  ends  of  its  hard  edges,  as  a  small  bony  projection  in  front  of  the 
foramen,  with  a  slight  linear  depression  (the  white  line  or  arcus  ten- 
dineus)  leading  forward,  and  marking  the  junction  of  the  pelvic  wall 
and  pelvic  floor.     (Figs.  18  and  19.) 

The  Pyriformis. 

Behind  the  small  sacro-sciatic  ligament  may  be  felt  the  pyriformis 
muscle  which,  in  a  state  of  rest,  is  flat,  and  considerably  softer  than 
the  ligament;  but  which,  during  contraction,  feels  like  a  small  pear- 
shaped  tumor  lying  upon  the  sacrum,  filling  the  upper  part  of  the 
sacro-sciatic  foramen  and  reaching  with  its  smaller  tapering  end 
diagonally  downward   and    outward   behind  the  ischial  spine.     By 


100 


EXAMIXATIOX    OF    THE    FEMALE    PEL^TlO    OEGAXS. 


directing  the  patiert  to  rotate  the  thigh  inward  and  outward  or  raise 
her  hips  a  little,  or  by  slightly  changing  her  position,  or  that  of  her 
feet,  or  approximating  her  knees,  contraction  and  relaxation  of  the 
muscle  may  be  successively  evoked. 

The  Great  Sacro-Sciatic  Foramen  and  Sacral  Promontory. 

Pushing  the  finger  from  the  ischial  spine  across  the  smaller  end  of 

the  muscle,  upward  and  backward,  the  bony  upper  border  of  the  great 
sciatic  foramen  at  the  sacro-iliac  synchondroses  is  felt,  and  may  be 


m 


Fig.  60. 


'^^ill&§i;i.'*K^'^  f£z£g-2-? 


:» 


t-1 


S52<^j 


w- 


^BS^m  M 


Anterior  Surface  of  the  Sacrum,  showing  the  Attachment  of  the  Pyriformis.    (After  Gray.) 

traced  toward  the  median  line.  Farther  up  the  promontory  may  be  felt. 
The  upper  border  of  the  great  sacro-sciatic  foramen  may  often  be 
reached  with  two  fingers  in  ordinary  ofi&ce  examinations,  whereas  the 
promontory  can  be  thus  touched  only  when  the  vagina  and  perineum 
are  relaxed  and  the  j^arts  behind  the  uterus  are  devoid  of  any  unusual 
sensitiveness.  The  ijrojecting  edges  of  the  sacral  foramina  can  also  be 
easily  felt,  the  first  one  just  above  the  internal  and  upper  angle  of  the 


THE    LEVATOR   ANI.  101 

raised  belly  of  the  contracted  pyriformis  muscle,  the  second  and  third 
at  the  depressions  or  scallops  of  its  internal  border,  and  the  fourth  just 
internal  to  its  lower  angle  or  edge.     (See  Fig.  60.) 

The  Coccygeus. 

Coming  forward  over  the  small  sacro-sciatic  ligament  the  finger 
barely  detects  the  fibrous  structure  of  the  flattened  coccygeus  lying 
upon  it,  until  it  has  passed  the  ligament,  when  it  immediately  recog- 
nizes the  clepressible  semi-elastic  character  of  the  relaxed  anterior  por- 
tion of  the  muscle.  Its  anterior  edge  or  border  is  often  prominent  as 
compared  with  the  levator  ani  in  front  of  it,  and  may  be  known  by 
locating  the  ischial  spine  and  last  coccygeal  articulation,  between 
which  it  runs  in  a  straight  line.  The  anterior  border  of  the  ligament 
may  be  known  from  that  of  the  muscle  not  only  by  its  rigidity,  but 
also  by  its  direction,  which  is  more  backward  from  the  ischial  spine 
toward  the  middle  or  upper  part  of  the  coccyx  than  the  muscle.  In 
the  ordinary  dorsal  position  the  border  of  the  ligament  seems  to  run 
from  the  ischial  spine  inward  and  slightly  backward,  that  of  the  muscle 
inward  and  slightly  forward.  When  the  coccygeus  is  contracted,  firm 
pressure  will  be  required  to  reach  and  recognize  the  anterior  edge  of 
the  ligament  through  the  substance  of  the  overlapping  muscle. 

The  Levator  Ani. 

The  levator  ani,  occupying  almost  the  entire  pelvic  floor  in  front  of 
the  coccygeus,  lies  directly  under  the  finger  pressed  flat  upon  the 
pelvic  floor  beside  the  rectum.  When  relaxed  it  is  soft,  concave  and 
depressible,  and  can  be  excited  to  partial  or  irregular  contractions  by- 
hooking  the  finger  tip  into  it  at  various  points.  When  contracted 
in  all  its  parts  it  renders  the  pelvic  fioor  hard,  less  concave  and  holds 
it  up  firmly  against  the  anterior  vaginal  wall.  Simultaneous  contrac- 
tion of  the  coccygeus  produces  a  smooth,  hard  floor  as  far  back  as 
the  great  sciatic  foramen.  If,  as  often  happens  in  ordinary  exami- 
nations, the  central  portion  alone  is  contracted,  the  finger  after  en- 
tering the  vagina  comes  upon  a  large  ridge  of  muscular  fibres,  ex- 
tending from  the  posterior  surface  of  the  pubic  bone,  at  the  anterior 
end  of  the  white  line  backwards  and  inwards  straight  to  the  end  of  the 
coccyx  forming  a  levator  coccygei  rather  than  a  levator  ani.  This  is 
theposterior  half  of  the  pubo-coccygeus  of  Savage.  (Fig.  18,  \)  Behind 
it  is  felt  the  relaxed  posterior  portion  as  a  triangular  depression  whose 
base  is  the  white  line  (arcus  tendineus),  whose  apex  is  at  the  lower 
coccygeal  bone  and  whose  sides  are  the  anterior  edge  of  the  coccygeus 
behind  and  the  contracted  portion  in  front.  This  is  the  obturato- 
coccygeus  of  Savage.  (Fig.  18,  \)  If  the  coccygeus  be  also  soft  and 
relaxed,  the  depression  including  it  will   be  quadrilateral..     If  the 


102  EXAMINATION    OF    THE    FEMALE    PELVIC    OEGANS. 

middle  section  of  the  levator  ani  be  very  strongly  contracted,  the  tri- 
angular space  often  becomes  narrower  by  a  participation  of  some  of 
its  anterior  fibres  in  the  contraction.  If  the  fibres  in  front  of  this  con- 
tracted band  or  central  portion  of  the  muscle  be  relaxed,  the  finger 
presses  down  with  the  rectum  against  the  coccygeo-anal  ligament ;  if 
they  be  greatly  relaxed  this  central  band  becomes  more  prominent, 
and  the  finger  lies  upon  an  almost  flat  surface  having  an  entirely  dif- 
ferent plane  from  the  deeper  pelvic  floor,  and  turning  abruptly  from 
it,  instead  of  continuing  forward.  As  thus  felt  the  anterior  portions  of 
the  levatores  ani  of  both  sides  taken  together  form  a  large  triangle 
whose  apex  is  at  the  tip  of  the  coccyx,  and  whose  basal  angles  are  at 
the  pubic  attachments  of  the  contracted  central  portion  or  levatores 
coccygei. 

When  the  posterior  section  alone  is  contracted  it  seems  to  form  a 
continuation  forward  of  the  contracted  coccygeus,  and  sometimes 
whether  contracted  alone  or  with  the  whole  floor  draws  the  white  line 
into  a  slight  curve  whose  concavity  is  outwards.  A  contraction  of  only 
the  anterior  portion,  which  has  no  central  bony  attachment,  raises  the 
pelvic  floor  edge  and  recto-vaginal  promontory  over  it  so  as  to  place  a 
distinct  fleshy  ridge  across  the  vaginal  inlet  behind  which  the  finger 
end  passes  abruptly  back  to  the  deeper  and  softer  parts.  Contraction 
of  the  central  with  the  anterior  portion  makes  this  ridge  much  wider. 
(See  Fig.  21.) 

Figs.  18  and  19,  from  Savage,  show  quite  truthfully  the  origin  and 
insertion  of  the  different  sets  of  fibres  of  these  muscles  and  are  worthy 
of  a  close  study.  The  finger-end  by  pressing  into  the  muscles  at  vari- 
ous points  as  already  directed  can  easily  determine  the  direction  and 
action  of  the  fibres  during  the  irregular  contractions  thus  induced. 

Control  of  the  Pelvic  Floor  Muscles  by  Will. 

As  the  levator  ani  and,  to  a  certain  extent,  the  coccygeus  are  volun- 
tary muscles,  the  patient  can  be  made  to  elevate  this  part  of  the  pelvic 
floor  as  the  finger  lies  upon  it.  My  attention  was  called  to  the  con- 
trol of  the  will  over  the  levator  ani  by  an  interesting  article  by  Budin* 
in  which  he  asserts  that  some  women  can  voluntarily  contract  the 
levator  ani.  For  the  purpose  of  getting  at  the  facts  I  tested  the  mat- 
ter in  seventy-five  consecutive  gynecological  patients  in  office  practice. 
I  asked  them,  while  holding  my  finger  in  the  vagina,  to  contract  the 
anus  as  after  a  stool,  or  as  to  prevent  a  passage  from  the  bowels.  By 
telling  them  that  I  was  trying  the  strength  of  the  uterine  supports  I 
succeeded  in  getting  all  but  one  to  make  the  effort.  All  but  this  one 
succeeded  in  raising  the  anterior  or  middle  portions  ;  nearly  all  raised 
also  the  coccygeus  ;  and  about  ten  per  cent,  raised  the  whole  plane  of 

*  Obstetriqne  et  Gynecologie,  1886.     Le  Progres  Medical,  Angnst,  188L 


THE  OBTURATOR  INTERKUS.  103 

the  pelvic  floor  from  the  coccygens  forward.  In  a  few  cases  the  ante- 
rior and  middle  portions  were  raised  along  with  the  levator  vaginse  so 
high  that  the  finger  had  to  pass  up  behind  the  pubes  to  get  over  them, 
i.e.,  the  pelvic  outlet  was  voluntarily  closed  up.  Fig.  21  represents  in 
section  a  contracted  jDclvic  floor  through  the  median  line  or  lowest 
part.  Virgins  seemed  to  have  as  good  control  over  the  pelvic  floor  as 
multipara  and  married  nullipara.  Injuries  during  labor  impair  the 
contractile  power  of  the  pelvic  floor  and  perineum  in  many,  as  will  be 
explained  in  describing  the  injuries  of  these  parts. 

The  Obturator  Internus. 

The  relaxed  internal  obturator  muscle  is  seldom  felt  in  an  ordinary 
examination  unless  especially  sought  for.  It  lies  flat  over  the  obtu- 
rator foramen,  partly  under  the  levator  ani  and  white  line  of  division 
of  the  obturator  fascia,  and  23artly  above  them  on  the  lateral  pelvic 
wall.  (See  Fig.  15.)  Its  higher  portion  is  easily  detected  above  the 
white  line  cushioning  the  pelvic  wall,  while  the  remainder  may  be 
reached  by  depressing  the  relaxed  middle  and  posterior  portions  of 
the  levator  ani  downward  and  outward  through  the  ischio-rectal  fossa 
until  firm  resistance  is  encountered.  When  contracted,  however,  the 
obturator  internus  feels  like  a  hard  hemispherical  tumor  on  either  side 
of  the  median  line,  over  the  obturator  foramen,  filling  the  ischio-rectal 
fossa,  and  elevating  the  pelvic  floor.  Between  the  two  bellies  there 
extends  a  narrow,  deep  characteristic  groove  along  the  median  line 
whose  bottom  is  the  coccyx  and  ano-coccygeal  ligament.  By  pushing 
aside  the  rectum  which  loosely  fills  the  groove,  the  borders  of  the  hard 
belly  of  the  contracted  muscle  may  be  easily  traced. 

We  may  distinguish  these  muscles  from  adventitious  growths  by  the 
fact  that  they  are  bilateral,  or  may  be  made  so  by  causing  the  patient 
to  rotate  the  trochanters  outward  against  counter-pressure  ;  and  that 
at  the  same  time  the  pyriform  muscles  are  generally  found  contracted, 
tumor  like;  while  the  depressed  flat  surface  of  the  small  sacro-sciatic 
ligament  lies  normally  between  the  two  rounded  tumors.  When  in 
addition  to  contraction  of  the  obturator  internus  and  pyriformis,  the 
levator  ani  and  coccygeus  are  also  contracted,  the  finger  finds  the  pos- 
terior vaginal  wall  and  whole  pelvic  floor  elevated  and  extending  as  a 
hard  mass  almost  straight  back  from  the  recto-vaginal  promontory  to 
the  small  sacro-sciatic  ligament.  This  ligament,  instead  of  a  raised, 
flat,  hard  surface  in  front  of  a  soft  and  yielding,  somewhat  concave 
pelvic  floor,  is  now  a  narrow,  depressed  surface  behind  a  firm  flat  or 
convex  surface,  and  in  front  of  the  raised,  tapering  belly  of  the  pyri- 
formis. When  the  levator  ani,  the  coccygeus  and  the  pyriformis  are 
contracted  but  the  obturator  internus  relaxed,  the  ligament  is  depressed 
compared  with  the  pyriformis  behind,  but  is  about  on  a  level  j)lane 
with  the  muscles  in  front. 


104  EXAMINATION    OF   THE    FEMALE   PELVIC   ORGANS. 

Rectal  Examination  of  the  Pelvic  Floor. 

As  already  indicated  in  speaking  of  the  rectal  examination  of  the 
pelvic  roof,  p.  90,  the  finger,  as  soon  as  it  has  passed  the  anal  sphinc- 
ters comes  in  contact  with  the  posterior  wall  of  the  rectum  as  loosely 
held  forward  by  the  anterior  portion  of  the  levator  ani.  This  is  the 
part  that  is  often  felt  per  vagina m  to  be  soft  and  depressible  in  front 
of  the  contracted  middle  portion,  or  levator  coccygei.  When  it  is  re- 
laxed its  resistance  is  scarcely  felt  by  the  well  oiled  and  properly 
directed  finger;  but  when  contracted  it  forms  a  firm  edge  or  projection 
almost  closing  the  passage  (Fig.  54).  In  order  to  get  over  it  upon  the  pel- 
vic floor  without  exciting  it  to  rigid  contraction,  the  finger,  after  being 
introduced  forward  to  the  anterior  rectal  wall,  or  near  it  (Fig.  54,/''), 
should  be  turned  palmar  surface  backward  (unless  it  has  been  so  in- 
troduced), and  bent  as  it  passes  further  in,  so  as  to  hook  around  and 
depress  the  pelvic  floor  edge  or  rectal  promontory.  The  rectum  will 
be  felt  to  lie  immediately  upon  the  pelvic  floor  so  as  to  afford,  practi- 
cally speaking,  a  direct  palpation  of  its  centre  and  often  of  its  left  side, 
and  if  it  be  voluminous  or  relaxed,  of  the  whole  pelvic  floor.  The 
ischio-rectal  fossa  on  either  side  is  separated  from  the  finger  by  less 
tissue  than  in  the  vaginal  examination.  On  the  contrary,  the  junction 
of  the  jDelvic  floor  with  the  lateral  pelvic  walls  anteriorly  cannot  be 
reached  as  easily  through  the  vagina  which  lies  higher  in  the  pelvic 
connective  tissue  chamber. 

The  nearness  of  all  parts  of  the  i^elvic  floor,  the  apparent  narrow- 
ness of  the  levator  ani  et  vaginae  which  is  partly  in  front  of  the  finger, 
the  distinctness  of  the  sensations  of  touch,  and  the  absence  of  certain 
parts  that  are  felt  in  the  vaginal  examination,  may  be  somewhat  con- 
fusing to  the  beginner,  but  constitute  in  reality  the  reason  for  such  an 
examination.  Having  located  the  coccyx,  ischial  spine  and  smaller 
sciatic  ligament  as  per  vaginam,  the  location  of  the  other  parts  becomes 
easy.  With  one  finger  the  sacrum  can  be  explored  as  high  up  as  the 
pelvic  roof,  its  curve  and  that  of  the  coccyx  be  estimated,  and  the 
lower  contents  of  its  hollow  be  examined  with  the  gentlest  and  most 
discriminating  touch. 

Contraction,  relaxation,  irritability,  inefficiency,  etc.,  of  the  muscles 
of  the  pelvic  floor  are  more  easily  appreciated  and  studied  than  Avhen 
felt  through  the  vagina,  where  the  levator  vaginae,  vaginal  wall,  rectum, 
and  connective  tissue,  as  well  as  the  greater  distance  of  the  parts, 
render  the  sensations  less  distinct. 

Palpation  of  the  Arteries  of  the  Pelvis. 

In  palpating  an  artery  in  the  pelvis,  we  hold  the  finger  perfectly 
still,  after  finding  the  tissues  through  which  the  vessel  runs,  until  we 
detect  its  pulsations,  and  then  trace  it  by  them  in  both  directions. 


VAGINAL,   PALPATION    OF    ARTERIES  105 

When  pressed  against  a  hard  or  resistant  surface  it  feels  like  a  cord, 
and  may,  if  passed  by  in  haste,  be  mistaken  for  other  structures,  such 
as  the  ureters,  a  deep  cicatrix,  a  nerve,  a  tendon,  ligament,  etc. 

Vaginal  Palpation  of  Arteries. 

The  pulsating  uterine  artery  is  found  on  either  side  of  the  cervix  by 
pressing  high  up  in  the  anterior  or  posterior  fornix  and  then  around 
to  the  side  of  the  uterus,  or  by  pressing  straight  out  from  the  lateral 
fornix  and  up  under  the  base  of  the  broad  ligament.  The  firmness 
of  the  connective  tissue  about  the  artery,  or  the  resistance  of  the  vagi- 
nal walls,  may,  however,  frustrate  such  attempts.  When  the  cervix  is 
situated  well  back  the  artery  is  often  found  farther  back  than  would 
be  supposed.  By  hooking  the  finger  up  behind  the  outer  attachment 
of  the  base  of  the  broad  ligament  the  uterine  artery  may  occasionally 
be  felt  entering  the  broad  ligament.  When  found  beside  the  cervix  it 
may  sometimes  be  traced  to  its  origin  above  and  behind  the  ischial 
spine. 

A  vaginal  branch  may  nearly  always  be  felt  pulsating  near  or  against 
the  cervix,  in  front  and  to  the  side  of  it,  and  can  be  traced  laterally 
almost  to  the  main  vessel  and  forward  down  the  anterior  vaginal  wall. 
Sometimes  it  dips  into  the  connective  tissue,  or  divides  irregularly  and 
is  lost  to  the  touch  near  the  cervix. 

The  middle  vesical  artery  is  often  felt  traversing  the  pelvic  roof  near 
.  the  ureter,  and  may  be  known  from  it  by  its  pulsations. 

The  internal  ej)igastric  artery  can  also  be  reached  and  recognized  by 
depressing  the  abdominal  wall  with  the  hand  externally  over  the  mid- 
dle of  Poupart's  ligament,  and  pressing  up  the  vaginal  finger  about  the 
internal  abdominal  ring.  (See  Palpation  of  the  Round  Ligament,  p. 
74.)  The  pulsations  may  be  traced  from  the  ring  a  short  distance  up 
the  abdominal  walls.  Numerous  small  tendons  on  the  under  surface 
of  the  transversalis,  passing  in  various  directions,  tend  to  confuse  the 
touch,  but  may  be  known  by  the  absence  of  pulsations  in  thein. 

The  internal  pudic,  escaj)ing  at  a  point  above  and  behind  the  ischial 
spine,  may  be  felt  by  passing  the  finger  tip  over  and  behind  the  ischial 
spine  along  the  pelvic  wall  below  the  uterine  artery,  or  by  placing  the 
finger  end  upon  the  pyriformis  muscle  and  carrying  it  forward  to  the 
spine.  It  is  felt  to  pass  into  (really  out  through)  the  great  sacro- 
sciatic  foramen  in  front  of  the  muscle.  Just  internal  and  back  of  the 
pudic,  usually  separated  by  a  sacral  nerve  running  between  them,  is 
felt  the  sciatic  also  passing  out.  Being  large  arteries  and  so  near 
together  they  may  be  both  felt  at  the  same  time  and  recognized  by  being 
together  and  disappearing  so  near  together.  When  they  are  given  off 
very  low,  only  one  artery,  the  anterior  trunk  of  the  internal  iliac,  may 
be  felt  in  their  place  pulsating  strongly  as  far  down  as  the  sacral 
plexus. 


106  EXAMIXATTOX    OF    THE    FEMALE   PELVIC   OEGAXS. 

By  pushing  backwards  across  the  pj^riformis  the  gluteal  artery  is  felt 
to  pass  down  and  disappear  behind  and  external  to  it.  "When  the  upjjer 
border  of  the  greater  sciatic  foramen  can  be  reached,  the  gluteal  will  be 
found  pulsating  strongly  as  it  comes  between  the  finger  and  the  bony 
edge.  It  may  be  traced  downward  to  the  edge  of  the  muscle  and 
upward  to  the  internal  iliac. 

The  middle  hemorrhoidal  is  easily  traced  downward  and  inward 
from  behind  the  ischial  spine  toward  the  rectum,  to  disappear  at  the 
recto-vaginal  septum  near  where  the  os  uteri  impinges  against  the 
posterior  vaginal  wall. 

The  inferior  vesical,  given  off  from  the  middle  hemorrhoidal,  or  near 
it,  is  felt  internal  to  and  below  the  ischial  spine  and  can  be  palj^ated 
upon  the  levator  ani  laterally  a  short  distance  below  the  obturator  to 
the  sides  of  the  pelvic  floor  outlet.  The  finger  introduced  into  the 
vaginal  entrance  and  laid  flat  upon  the  belly  of  the  levator  ani  on 
either  side  will  almost  immediately  feel  the  artery  pulsating  and  can 
trace  it  backward. 

The  obturator  artery  is  easily  felt  running  forward  along  the  lateral 
pelvic  wall,  over  the  spine  of  the  ischium  near  the  upper  edge  of  the 
obturator  internus  toward  the  opening  through  which  it  leaves  the 
pelvis.  Its  course  lies  a  little  above  and  almost  parallel  with  the  white 
line.  From  here  a  branch  can  usualh^  be  traced  along  the  posterior 
surface  of  the  pubic  bone  to  join  its  fellow  from  the  Of)posite  side. 
An  obturator  branch  of  the  epigastric  can  generally  be  traced  from  the 
foramen  upward  and  forward  toward  the  internal  abdominal  ring,  to 
which  it  may  sometimes  serve  as  a  guide. 

The  sacra-media  may  often  be  recognized  per  vaginam  by  pressing 
firmly  against  the  sacrum  in  the  median  line  high  up  behind  the 
cervix.  On  account  of  its  bony  bed  the  pulsations  seem  quite  strong. 
Satisfactory  palpation  of  the  smaller  arteries  situated  at  a  distance 
from  hard  or  bony  surfaces  is  only  possible  when  the  connective  tissue 
is  not  too  firm,  or  when  their  course  is  near  the  mucous  membrane  of 
the  vagina;,  or  when  the  abdominal  wall  can  be  pressed  down  so  as  to 
form  a  resistant  surface  over  them.  The  main  trunks  of  the  internal 
iliacs  can,  under  favorable  circumstances  and  under  ether,  be  found  by 
tracing  the  anterior  and  posterior  branches  upward. 

The  irregularities  in  size  and  origin  of  the  vesical,  uterine  obturator, 
and  pudic  arteries  in  dififerent  subjects,  and  in  the  two  sides  of  the 
same  subject,  and  the  occasional  crowding  together  or  union  of  the 
points  of  origin  of  two  or  more,  or  of  all,  of  the  branches  of  the  internal 
iliacs,  make  it  often  impossible  to  trace  them  all  to  and  from  their 
sources. 

In  a  dissection  made  for  the  purpose  of  a  description  I  found  both  sides  unnsnal  and 
at  the  same  time  as  diflerent  from  each  other  as  possible.  Tlie  places  of  division  of 
both  internal  iliacs  were  higli  up,  and  both  obturator  arteries  were  given  off  from  the 


PALPATION   OP    PELVIC   NEEVES.  107 

posterior  trunks.  On  the  left  side  the  anterior  trunk  was  less  than  an  inch  long  to 
where  it  bifurcated  into  the  sciatic  and  pudic.  The  uterine  and  superior  vesical  arose 
by  a  common  track,  the  first  giving  off"  the  vaginal,  the  second  the  middle  vesical.  The 
middle  hemorrhoidal  gave  off"  the  inferior  vesical.  On  the  right  side  the  anterior 
trunk  extended  as  an  almost  straight  tube  for  more  than  two  inches  and  divided  into 
the  internal  pudic  and  sciatic  just  over  the  sacral  plexus.  The  only  other  branches 
given  off  were  the  superior  vesical,  with  its  middle  vesical  branch,  and  the  uterine 
artery.  This  last  was  given  off"  high  up,  and  descended  beside  the  long  anterior  trunk 
of  the  internal  iliac  for  about  an  inch  before  turning  into  the  broad  ligament.  All  of 
the  other  arteries  arose  from  the  posterior  trunk.  This  variability  in  the  diff"erent 
subjects,  and  in  the  sides  of  the  same  subject  is  a  strong  reason  for  the  practice  of 
digital  palpation  of  the  arteries,  so  that  the  operator  need  not  depend  upon  his  knowl- 
edge of  where  they  ought  to  be,  but  may  map  them  out  with  the  finger  as  they  happen 
to  be  before  cutting  in  among  them. 

Rectal  Palpation  of  the  Pelvic  Arteries. 

When  the  rectum  is  of  moderate  size,  and  normally  located  a  trifle 
to  the  left,  the  index  finger  of  the  right  hand  introduced  into  it 
scarcely  notices  any  arteries  except  the  sacra-media,  unless  it  presses 
far  toward  the  right  side  of  the  jDclvis ;  but  the  left  index,  if  introduced 
and  allowed  to  lie  still  a  moment,  is  apt  to  feel  as  if  in  a  nest  of  j)ulsat- 
ing  arteries,  and  to  get  confused  at  the  number  of  vessels  about  it — 
more  particularly  so  as  smaller  branches  are  here  palpable.  The  small 
sciatic  ligament  and  pubic  sjpine  should  in  such  a  case  be  located,  or, 
if  the  pelvic  floor  be  raised  so  as  to  hide  them,  the  contracted  pyri- 
formis  and  great  sacro-sciatic  notch.  The  vessels  before  and  behind 
the  pyriformis  may  then  be  sought  the  same  as  directed  above  in  the 
vaginal  examination,  and  will  be  reached  with  greater  ease.  Those 
passing  across  the  pelvic  roof  are,  however,  not  so  easily  recognized. 
The  middle  hemorrhoidal  will  be  above  instead  of  below  the  finger, 
and  may  often  be  pressed  against  the  cervix. 

Palpation  of  Pelvic  Nerves. 

Nerves  to  be  felt  in  the  pelvis  must  usually  be  pressed  against  a  hard 
surface.  As  a  rule  they  are  to  be  sought  near  the  arteries  of  the  same 
name.  Thus  the  obturator  nerve  may  be  reached  from  the  vagina 
lying  against  the  hard  pelvic  wall,  a  little  above  and  parallel  to  the 
obturator  artery,  and  the  superior  gluteal  and  pudic  nerves  beside  the 
arteries  of  the  same  name.  The  sacral  plexus  lying  upon  the  pyri- 
formis feels  like  flat,  slightly  movable  bands  connected  together,  coming 
from  the  sacral  foramina  and  disappearing  with  the  tendon  of  the 
muscle  behind  the  ischial  spine.  The  mobility  of  this  plexus  and  the 
ease  of  its  detection  also  affords  a  sort  of  index  to  the  firmness  of  the 
connective  tissue  about  them.  Although  thus  exposed  to  easy  pressure 
by  the  finger  in  the  vagina,  they  are  in  reality  well  protected  by  lying 
in  the  sacral  concavity,  with  large  arteries  about  them,  and  the  sacro- 


108  EXAMINATION    OF    THE    FEj\IALE   PELVIC   ORGANS. 

uterine  and  broad  ligaments  and  sacral  pouches  extending  above  and 
over  them.  Inflammatory  exudations  cause  pressure  upon  them  more 
often  than  anything  else,  although  I  have  seen  one  case  of  pressure 
from  a  suddenly  dislocated  fundus  uteri  upon  the  superior  gluteal,  caus- 
ing intense  suffering  throughout  the  extent  of  the  nerve,  until  as  sud- 
den and  permanent  relief  was  afforded  by  a  replacement  of  the  organ. 
Pain  upon  pressure  running  along  the  course  of  the  nerves  is  often 
a  great  help  in  hunting  for  them.  Thus  in  palpating  the  superior  edge 
of  the  greater  sciatic  foramen  (p.  100),  when  we  pass  over  the  pulsating 
gluteal  artery  we  can  feel  the  nerve  as  a  smaller  cord  running  alongside 
it,  and  will  know  it  by  the  sudden  sharp  pain  felt  by  the  patient  as 
the  nerve  slips  under  the  finger.  The  pain  is  referred  to  the  hip  and 
gluteal  muscles.  Similarly  in  front  of  the  pyriformis,  and  near  the 
respective  arteries  firm  pressure  upon  the  small  sciatic  or  pudic  nerves 
will  sometimes  be  referred  to  the  posterior  and  inner  side  of  the  upper 
thigh  or  about  the  external  genitals.  Pressure  upon  or  above  the 
coccygeus  near  the  median  line  frequently  causes  acute  jDain  in  the 
pelvic  floor  along  the  course  of  branches  of  the  4th  and  5th  sacral 

nerves. 

Examination  of  the  Perineum. 

In  considering  the  perineum  as  separated  from  the  pelvic  floor 
(see  Chapter  I.)  the  levator  vagin&e  portion  of  the  levator  ani  was 
described  as  a  separate  muscle  attached  anteriorly  to  the  posterior 
surface  of  the  pubes,  just  external  to  the  urethral  notch,  and  poste- 
riorly to  the  recto-vaginal  septum  just  behind  the  hymen.  (Figs.  16, 
17,  22  and  31.) 

Examination  of  the  Vaginal  Orifice. 

The  Hymen. — The  hymen  extends  from  the  urethra  just  behind  the 
meatus  urinarius  down,  on  either  side,  along  the  perineal  septum  to  the 
perineal  body,  forming  a  curtain  or  screen  at  the  vaginal  orifice  across 
the  lower  ends  of  the  urethral  and  rectal  notches.  (See  Fig.  16  for 
these  notches.)  According  as  its  aperture  is  central  or  peripheral, 
high  or  low,  single  or  double,  etc.,  the  shape  of  the  ridge  of  membrane 
around  the  vaginal  orifice  varies,  but  to  the  finger  passed  into  the 
vagina  it  usually  feels  like  a  firm,  narrow  ridge  or  elastic  ring.  When 
dilated  or  partially  ruptured  from  coitus  it  is  felt  as  one  or  more  loose 
ribbon-like  folds  of  membrane  extending  partly  or  quite  around  the 
vaginal  orifice;  when  destroyed  by  parturition  its  remains  are  felt  as 
a  series  of  soft  projections  (the  caruncles)  in  the  same  place,  or  a  trifle 
external  to  it;  when  absorbed  or  atrophied  from  injury  or  age  it  may 
leave  no  trace  of  itself  to  the  touch,  and  but  little  to  the  sight. 

The  Levator  Vaginse  and  Levator  Ani. 

In  the  virgin  the  posterior  and  lateral  vaginal  walls  sliould,  by  the 
action  of  the  levator  vaginse  or  vaginal  sphincter,  be  firmly  approxi- 


THE  LEVATOR  VAGII«r^  AND  LEVATOR  ANI.         109 

mated  to  the  finger  introduced  through  the  hymen.  The  muscle  ex- 
tends around  the  vagina  and  feels  like  a  broad  band  or  sling  instead 
of  a  narrow  rigid  edge  like  the  uninjured  hymen  (Figs.  17  and  22), 
Above  on  either  side  of  the  urethra  are  felt,  upon  upward  pressure,  the 
urethral  notches  giving  the  orifice  a  crescent  shape  (Fig.  61).  In  the 
married  woman  the  levator  vaginae  is  ordinarily  somewhat  relaxed, 
and  sinks  slightly  into  the  rectal  grooves  on  either  side  of  the  rectum, 
causing  the  latter  to  present  a  broad  elevation,  the  recto-vaginal  pro- 
montory just  behind  the  hymen  in  the  median  line  (Fig.  16)  where  it 
passes  over  the  pelvic  floor  edge  into  (or  out  of)  the  pelvis.  The  orifice 
then  is  felt  to  be  transversely  oblong  with  the  upper  and  lower  sides 
depressed  by  the  urethra  and  rectum  (Fig.  62).  To  the  touch  the 
vaginal  entrance  feels  a  little  wider  over  the  rectum  than  in  Fig.  16 
(which  represents  the  parts  collapsed),  because  when  the  parts  are 
examined  by  the  finger  they  reveal  the  shape  and  capacity  only  when 
dilated  to  the  extent  of  affording  a  characteristic  resistance.     When 

Fig.  61.  Fin.  62  Fig.  63. 

]i.Ur^th.aZJiotc7u                                   'PiCbieAreh 
J  ■     A      ?  Vrethra  .., 

\  '■■" V''' "  --  . .  ,/--'  /T'^^'X.  y''*'^^TX'^''  fv^i^  Avclv 


Fig.  61, — Vaginal  Entrance  of  the  Virgin. 
Fig.  62. — Vaginal  Entrance  of  the  Married  Nullipar. 

Fig.  63.— Vaginal  Entrance  of  the  Married  Nullipar  with  contracted  or  short  Levator  Ani,  draw- 
ing forward  the  rectal  and  recto-vaginal  promontories. 

the  anterior  portion  of  the  levator  ani,  that  portion  which  passes  to 
and  under  the  rectum,  is  contracted  or  normally  short,  the  rectum  is 
pressed  firmly  up  against  the  urethra,  leaving  a  little  space  on  either 
side  between  the  rectal  and  urethral  notches  (Fig.  63). 

When  the  levator  vaginae  and  its  surrounding  fasciae  are  relaxed  to 
an  extreme  degree,  so  as  to  give  no  resistance  whatever,  the  urethral 
notches  are  considerably  widened  to  the  touch,  for  the  finger  before 
encountering  resistance  comes  against  the  fibres  of  the  levator  ani 
proper,  whose  pubic  attachments  are  farther  away  from  the  urethra. 
These  fibres,  instead  of  passing  almost  straight  back  at  their  commence- 
ment, like  the  levator  vaginae,  assume  from  their  origin  a  diagonal 
direction  and  converge  quite  rapidly  inward  towards  the  sides  of  the 
rectum.  The  finger  finds  itself  in  a  V-shaped  orifice  with  the  rectum 
filling  the  angle  and  the  urethra  projecting  into  its  open  end.  Fig.  64 
shows  approximately  the  shape  as  ascertained  by  the  touch.     When 


110 


EXAMINATIOX   OF   THE    FEMALE    PELVIC   ORGANS. 


the  levator  vaginae  is  greatly  relaxed,  and  the  levator  ani  short  or  con- 
tracted, the  rectum  is  brought  up  against  the  urethra  and  the  borders 
of  the  levator  ani  or  arms  of  the  V  are  more  transverse  and  form  a 
larger  angle,  as  in  Fig.  65.  The  rectal  notches  are  well  marked,  and 
broad  but  shallow.  AVhen  the  levator  vaginse  is  extremely  relaxed 
the  finger  entering  the  vagina  along  its  posterior  wall  on  either  side 
of  the  recto-vaginal  promontory  comes  against  the  under  surface  of 
the  pelvic  floor  edge  or  levator  ani  instead  of  being  directed  imme- 
diately over  it,  as  is  the  case  when  the  vaginal  entrance  is  drawn  to- 
gether at  the  pelvic  floor  edge  by  the  levator  vaginse. 

Each  of  these  forms  denotes  a  particular  condition:  the  first  (Fig. 
61),  a  contracted  or  tonic  condition  of  the  vaginal  coats,  in  the  levator 
vaginse,  the  fascia  and  the  surrounding  connective  tissue,  and  is  found 


Fig.  64. 

XTrdhrai  notches 


TJr^tl%TCL 


JiiieteCLTiraAuixtitoxif 

Fig.  64.— Vaginal  EntraDce,  witli  greatly  relaxed  or  destroyed  Levator  Vaginse. 
Fig.  65.— Same  as  Fig.  64,  except  that  the  Levator  Ani  is  short  and  practically  closes  the  Vagina 
(just  behind  its  entrance). 


in  virgins  and  some  married  nullipara;  the  second  (Fig.  62),  a  normal 
relaxation  of  these  tissues,  and  is  found  in  some  virgins  and  most 
married  women;  the  third,  contraction  of  the  anterior  edge  of  the 
levator  ani  so  as  to  raise  the  pelvic  floor  edge  (Fig.  63);  the  fourth, 
complete  relaxation  of  the  levator  vaginse  with  a  normal  levator  ani, 
as  is  found  after  over-distension  or  injury  at  childbirth  (Fig.  64)  ;  the 
fifth,  complete  relaxation  of  the  levator  vaginse  with  shortness  or  con- 
traction of  the  levator  ani  anteriorly  (Fig.  65).  With  the  last  condi- 
tion we  may  have  a  firm  closure  of  the  vagina  just  behind  the  hymen 
coexistent  with  relaxed  or  patent  vaginal  or  vulval  orifices. 


Examination  of  the  Vulval  Orifice. 

The  vulval  orifice  usually  feels  larger  than  the  vaginal.  Anteriorly 
it  is  slightly  indented  by  the  urethra  but  extends  posteriorly  beyond 
the  rectal  promontory  to  the  fourchette. 


THE   PUBIC    FOSSA. 


Ill 


The  Constrictor  Cunni  or  Vulval  Sphincter. 

The  principal  variations  in  the  shape  of  the  vulval  orifice  are  occa- 
sioned by  the  condition  of  the  constrictor  cunni.  When  this  muscle 
and  the  surrounding  fasciae  are  firm,  as  in  some  virgins,  the  opening 
feels  almost  circular  to  the  finger  sweeping  around  it,  except  at  the 
anterior  portion  or  lower  end  of  the  urethra  (Fig.  66);  when  normally 
relaxed,  as  in  married  nullipara,  it  is  about  the  same  shape  but  large 
and  flabby,  and  slightly  indented  below  by  the  median  line  raph6 
(Fig.  67) ;  when  u.nusually  relaxed  from  overdistension  in  labor,  mus- 
cular debility,  frequent  coitus,  etc.,  it  allows  the  finger  to  pass  from 
the  inferior  pubic  ligament  down  along  the  inner  surface  of  the  pubic 
ramus  for  a  considerable  distance,  and  then  against  the  perineal  body 


Fig.  66. 


Fig.  67. 


Fig.  68. 


\   ^"^^      Cfredira. 


H^aofcohicrictarcwml  Tottrche-ftc  gloved  Constrictor  Ccotn^ 

Fig.  66.— Shape  of  Vulval  Orifice  of  Virgin  as  expanded  by  the  Examining  Finger. 
Fig.  67.— Same,  of  Married  Nullipar. 
Fig.  68. — Same,  of  Childbearing  Woman. 


in  a  slight  depression  between  the  median  line  raphe  of  the  perineal 
body  and  the  bone  (Fig.  68).  The  sagging  of  the  muscle  on  either  side 
makes  the  fourchette  and  raphe  between  them  feel  like  a  raised  ridge. 
The  figure  then  traced  becomes  wider  below  than  normal  and  has  a 
distinct  indenture  both  anteriorly  and  posteriorly,  viz.,  the  urethra 
and  median  line  raphe. 

The  Pubic  Fossa. 

Extreme  relaxation  or  a  loss  of  integrity  of  both  the  levator  vaginae 
and  the  constrictor  cunni  with  their  fasciae  not  only  enlarges  the  vulvo- 
vaginal outlet  so  as  to  allow  the  pubic  rami  to  be  palpated  down  some 
distance  below  the  superior  pubic  ligament,  but  gives  rise  on  either 
side  to  a  distinct  well-defined  fossa  between  the  muscles.  The  base 
or  bottom  of  this  pubic  fossa  is  the  inner  surface  of  the  pubic  ramus ; 
its  external  border  is  the  relaxed  constrictor  cunni  and  the  labium 


112  EXAMIXATIOX    OF   THE    FEMALE    PELVIC    OEGAXS. 

majus ;  its  internal  border  is  the  levator  vaginae  and  underlying 
anterior  edge  of  the  levator  ani ;  its  anterior  end  is  the  inferior  pubic 
ligament,  and  its  posterior  end  the  raised  or  projecting  perineal  raphe 
at  and  behind  the  fourchette.* 

The  distance  below  the  inferior  pubic  ligament  to  which  the  pubic 
ramus  can  be  traced  is  in  proportion  to  the  relaxation  or  destruction 
of  these  tissues.  In  the  virgin  the  bone  cannot  be  felt  because  the 
hymen  and  perineal  se]3tum  keep  the  tissues  between  the  levator 
vaginae  and  constrictor  cunni  raised  from  their  level  instead  of 
depressed  between  them.  When  the  hymen  and  perineal  septum  are 
stretched,  the  mucous  membrane  sinks  slightly  into  this  fossa  and 
divides  it  into  two  narrow  grooves,  continuous  in  front  with  the  fossa 
navicularis,  and  behind  with  a  corresponding  fossa  behind  the  hymen. 
A  rupture  of  the  hymen  involving  a  little  of  the  perineal  septum 
about  it,  allows  the  tissues  to  sink  laterally  against  the  pubic  rami  so 
as  to  form  the  fossa  without  any  relaxation  of  the  muscles,  except 
such  as  must  result  from  the  rupture  and  the  consequent  fascial 
deficiency. 

Transversus  Perinsei. 

When  the  pubic  fossa  is  well  marked  the  transversus  perinsei  can 
be  palpated.  A  prolongation  of  the  pubic  fossa  backward,  allowing 
the  finger  to  j^ass  back  along  the  pubic  and  ischial  rami  beyond  the 
median  line  raphe  and  beside  the  anal  sphincter,  is  presumptive  evi- 
dence that  the  transversus  perinsei  has  lost  either  its  tonicity  or  its 
integrity.  By  placing  the  finger  of  the  unemjDloyed  hand  in  the 
rectum  and  drawing  the  anus  to  one  side,  the  muscle  of  the  opposite 
side  becomes  tense  if  it  be  normal,  and  can  be  felt  as  a  ridge  deep  in 
the  jjosterior  end  of  the  fossa.  AVhen  the  fossa  does  not  reach  to  the 
muscle  the  finger  maj-  detect  its  tense  ridge  b}^  pressing  into  the  cuta- 
neous surface  of  the  perineum  beside  the  anterior  edge  of  the  abducted 
sphincter  ani.  The  transversus  perinsei  seems  farthar  back  than 
normal,  because  the  anterior  edge  of  the  sphincter  is  stretched  forward 
by  the  rectal  finger.  When  the  perineal  septum  is  relaxed  the  rectal 
finger  may,  if  the  vulva  be  pushed  to  the  opposite  side,  detect  the 
resistance  of  the  muscle.  Detection  of  the  muscle  in  this  way  is  a 
sign  of  a  relaxed  perineal  sej)tum.  Complete  relaxation  of  the  trans- 
versus perinsei  of  only  one  side  allows  the  sphincter  ani  to  be  drawn 
a  little  to  the  opposite  side. 

Characteristics  of  the  Perineal  Body. 

Relaxation  of  the  whole  perineum,  including  the  perineal  septum, 
fascise  and  connective  tissue,  is  recognized  by  a  sinking  down  and 
back  of  the  perineal  body,  more  particularly  its  anterior  end  or  base, 

*  These  characteristics  are  best  determined  by  palpation,  and  require  no  insoection. 


DIGITAL    EVERSION    OF    THE    VAGINA.  113 

SO  as  to  increase  the  projection  below  the  external  conjugate.  The 
hymen,  instead  of  being  drawn  up  under  the  pubic  arch,  sags  down 
and  becomes  more  exposed  posteriorly  between  the  separated  labia 
and  is  encountered  before  the  finger  gets  into  the  vaginal  entrance. 
The  fourchette  projects  but  little  above  the  surface  unless  the  labia 
are  stretched  widely  apart.  The  finger  introduced  into  the  rectum 
along  its  anterior  wall,  instead  of  being  directed  by  the  perineal  body 
up  behind  the  pubes,  passes  forward  under  or  in  front  of  the  arch. 
Such  relaxation,  even  when  co-extant  with  a  relaxation  of  the  sphincter 
ani,  is  not  necessarily  occasioned  by  nor  accompanied  by  any  exten- 
sive lesion  of  tissue,  and  may  be  followed  by  a  return  of  the  parts  to  a 
normal  condition.  Fig.  30  represents  a  section  of  the  perineal  body 
thus  relaxed. 

Rectal  Palpation  of  the  Perineal  Body. 

The  thickness  of  the  perineal  body  is  easily  determined  by  the 
finger  in  the  rectum,  the  thumb  on  the  cutaneous  surface,  and  the 
forefinger  of  the  free  hand  on  the  vulvo-vaginal  surface.  Figs.  26  to 
30  show  the  shape  of  the  tendinous  portion,  or  that  affording  firm 
resistance  to  the  touch.  Straightening  by  tension  (28  and  29),  curving 
by  relaxation  (30),  or  loss  of  substance  from  injury,  can  thus  be  easily 
appreciated.  The  amount  and  firmness  of  connective  tissue  on  the 
three  sides  is  known  by  the  amount  and  the  resistance  of  the  tissues 
over  the  tendinous  raphe.  The  firmness  of  the  structure  as  a  whole 
can  be  approximately  determined  by  drawing  down,  with  the  finger 
in  the  rectum,  and  thumb  or  finger  of  the  other  hand  in  the  vaginal 
orifice,  both  together.  The  amount  of  resistance  to  such  manoeuvres 
is  by  no  means  in  proportion  to  the  mere  amount  of  the  perineal 
body  that  may  have  been  destroyed,  as  will  be  explained  in  discussing 
perineal  ruptures.     (See  Chapter  VII.) 

Digital  Eversion  of  the  Vagina. 

The  finger  introduced  into  the  anus  and  passed  palmar  surface  for- 
ward along  the  anterior  rectal  wall,  comes  in  contact  with  the  recto- 
vaginal septum  at  the  recto-vaginal  promontory,  and  can,  with  but 
slight  inconvenience  to  the  patient,  evert  the  recto-vaginal  angle  of 
the  perineal  body,  and  lower  end  of  the  posterior  vaginal  wall,  for 
inspection.  This  is  particularly  easy  when  the  perineum  is  relaxed 
or  lacerated.     (See  diagnosis  of  perineal  lacerations.  Chapter  VII.) 


CHAPTER   IV. 

INSTRUTVIENTAL  EXAMINATION  OF  THE  FEMALE  PELVIC  OEGANS. 

Dr.  Simpson  recommended  and  practiced  the  use  of  the  sound  for 
the  purpose  of  examining  the  uterus,  and  he  has  given  to  it  a  certain 
appropriate  shape,  size,  and  adjustment,  which  adds  materially  to  its 
adaptability  to  this  particular  use. 

Object  in  Using  the  Sound  or  Probe. 

The  main  objects  in  examinations  with  the  sound  in  such  cases  as 
I  have  now  under  consideration  are,  to  measure  the  size  and  length 
of  the  cervical  and  uterine  cavities,  the  mobility  and  position  of  the 
uterus,  and 7  if  need  be,  the  connection  of  that  organ  with  pelvic 
growths.  At  the  present  time  a  number  of  flexible  sounds,  or,  more 
accurately  speaking,,  probes  have  also  been  constructed  for  cases  in 
which  the  alterations  in  size  and  shape  of  the  uterine  cavity  render 
the  larger  and  move  rigid  saund  almost  useless. 

Size  and  Length  of  Sound. 

It  should  be  ten  or  twelve  inches  long,  with  one  end  fixed  to  a  flat 
handle,  and  the  ather  terminated  with  the  ordinary  probe  point  en- 
largement, aboirt  one-eighth  of  an  inch  in  diameter.  The  wire  behind 
tha  bulbous  termination  should  be  one  line  in  diameter,  round  and 
smooth,  and  should  gradually  increase  in  size  to  the  handle,  where  it 
might  be  about  a  quarter  of  an  inch  in  diameter.  The  best  material 
is  copper,  galvanized. 

Simpson's  sound  is  larger  and  less  flexible  than  Sims's,  and  is  grad- 
uated or  marked  by  notches,  indicating  inches.  Jenks's  flexible  sound 
possesses  the  advantage  of  easily  adapting  itself  to  the  shape  of  the 
uterine  cavity.  Fitch's  measuring  sound  is  less  flexible  than  Jenks's, 
but  has  a  similar  sliding  sheath  for  marking  the  depth  of  the  uterus. 
Sims's  small  flexible  silver  probe  and  Thomas's  whalebone  sound  are 
valuable  substitutes  for  the  heavier  sound  when  we  wish  to  explore  a 
tortuous  or  very  deep  uterine  cavity. 

Accidents  of  serious  character  sometimes  occur  in  using  the  probe 
in  the  uterus.  Dr.  Engelman,  in  the  St.  Louis  Medical  and  Surgical 
Journal,  says  that  he  was  present  when  Professor  Carl  Braun,  of  Vienna, 
pushed  the  uterine  probe  through  the  tissues  of  the  uterus  into  the 
peritoneal  cavity.  Dr.  Noeggerath,  of  New  York,  mentions  a  case 
where  the  sound  had  been  passed  five  inches,  going  through  the  fundus 


SIZE    AND    LENGTH    OF   SOUND. 


115 


Titeri,  as  shown  by  the  discovery  of  a  cicatrix  at  a  post-mortem  exami- 
nation made  several  months  afterwards. 

Other  unquestionable  instances  of  this  accident  are  on  record.  Of 
these  cases  I  have  heard  of  none  in  which  any  untoward  consequences 
followed  what  would  seem  to  be  at  least  a  serious  occurrence.  As  all 
the  cases  published  were  in  the  care  of  skilful  and  practical  practi- 


FiG.  69. 


Fig.  70. 


Fig.  71. 


Fig.  72. 


Simpson's  Sound. 


Sims's  Sound. 


Jenks's  Uterine 
Sound. 


Fitch's  Measuring 
Sound. 


tioners,  their  occurrence  must  therefore  be  attributed  to  some  other 
circumstance  than  rashness.  The  probability  is  that  on  account  of 
disease  the  uterine  structure  had  become  too  frail  from  attenuation  or 
softening  to  resist  the  slight  force  used  to  introduce  the  probe.  It  is 
interesting  as  well  as  surprising  that  so  little  effect  followed  the  forci- 


116       INSTETJMENTAL,    EXAMINATION   OF    FEMALE   PELVIC   ORGANS. 

ble  entry  of  the  probe  to  the  uterine  wall  or  the  contents  of  the  peri- 
toneal cavity. 

The  Fallopian  tube  is  sometimes  so  patulous  from  disease  as  to 
permit  the  sound  to  pass  through  it  into  the  cavity  of  the  peritoneum. 
Where  the  whole  of  the  uterus  is  enlarged,  as  it  is  found  for  many 
days  and  sometimes  weeks  after  parturition,  the  uterine  orifice  of  the 
tube  is  large  enough  to  admit  the  probe.  This  may  be  the  case  also 
from  the  enlargement  caused  by  uterine  catarrh.  When  the  opening 
to  the  tube  is  thus  enlarged  it  requires  but  a  slight  inclination  of  the 
uterus  to  one  side  of  the  pelvis  to  bring  the  Fallopian  orifice  in  a 


Introduction  of  the  Uterine  Sound,  showing  the  movement  of  the  handle  (3^). 


direction  to  be  easily  entered  by  the  instrument.  When  once  it  has 
entered  the  tube  it  will  find  no  resistance  to  its  farther  progress. 

In  a  discussion  before  the  Obstetrical  Society  of  New  York,  January 
17th,  1871,  reported  in  the  Journal  of  Obstetrics  of  August,  1871,  Drs. 
Budd,  Thomas,  and  Noeggerath,  all  speak  of  cases  in  which  the  sound 
seems  to  have  enterejd  the  peritoneal  cavity  to  a  long  distance  through 
the  Fallopian  tube. 

Dr.  Rosa  Engert  was  kind  enough  to  show  me  a  case  quite  recently 
in  which  she  repeatedly  passed  the  sound  through  the  Fallopian  tube. 
When  the  end  of  the  instrument  had  reached  the  fundus  it  required 


LENGTH    OF    THE    CERVICAL    AND    UTERINE    CAVITIES.  117 

but  little  inclination  to  the  left  to  cause  it  to  enter  the  tube.  The 
patient  experienced  no  inconvenience  from  the  examination. 

Another  accident,  and  one  of  more  importance  because  of  its  almost 
invariably  fatal  effects  upon  the  embryo,  and  also  because  of  its  more 
frequent  occurrence,  is  the  damage  done  sounding  an  impregnated 
uterus. 

Too  great  caution  cannot  be  observed  in  making  investigation  of 
the  condition  of  the  uterus  before  passing  the  probe  into  its  cavity. 
I  have  known  two  instances,  however,  in  which  the  impregnated 
uterus  was  probed  to  a  depth  of  several  inches  without  interrupting 
gestation.  When  a  suspicion  of  pregnancy  exists,  there  can  hardly 
be  a  circumstance  so  grave  as  to  justify  the  use  of  the  probe. 

In  such  cases  we  should  unhesitatingly  wait  until  time  solves  the 
question  of  pregnancy. 

The  probe  should  not  be  used  during  menstruation,  nor  in  the 
presence  of  great  tenderness  in  or  about  the  uterus. 

Mode  of  Using. 

After  oiling  the  instrument,  and  introducing  the  index  finger  of  the 
right  hand,  and  placing  it  upon  the  os  uteri,  the  sound  may  be  carried 
along  the  palmar  surface  of  the  finger  until  the  point  arrives  at  the 
mouth  of  the  uterus,  when,  by  depressing  the  handle,  its  point  may 
.be  carried  forward  into  the  cavity  of  the  cervix.  In  order  to  insure 
its  passage  through  the  cavity  of  the  cervix  into  the  cavity  of  the 
body,  the  probe  must  be  bent  to  the  same  degree  as  the  male  catheter. 
Great  gentleness  must  be  observed  in  the  use  of  this  instrument,  be- 
cause it  is  an  easy  matter  to  do  violence  to  the  mucous  membrane  by 
a  very  little  rudeness  of  management.  After  the  sound  has  passed  to 
the  OS  internum,  a  sense  of  constriction  is  felt  through  the  instrument, 
which  feeling  soon  gives  way,  and  the  point  then  goes  to  the  fundus 
without  further  resistance. 

Length  of  the  Cervical  and  Uterine  Cavities. 

The  cervical  cavity  in  the  virgin  is  about  an  inch  and  a  quarter  in 
depth,  and  the  cavity  of  the  body  from  a  half  to  three-quarters  of 
an  inch ;  the  former  in  the  multipara  is  one  and  a  half  inches,  and 
the  latter  an  inch  deep.  In  old  age  both  are  nearly  or  wholly  oblit- 
erated. I  do  not  often  use  the  probe  in  this  way  for  the  examina- 
tion of  the  uterus  in  cases  of  inflammation  and  ulceration,  but  have 
adopted  the  suggestion  of  Professor  Miller,  of  Lnouisville,  and  use  it 
through  the  speculum,  and  shall  consequently  have  more  to  say  about 
it  in  connection  with  the  use  of  that  instrument. 

It  often  happens,  with  the  present  means,  that  there  is  great  diffi- 
culty in  determining  the  thickness  of  the  uterine  walls,  and  even  the 


118      INSTRTJMEXTAIi  EXAMIIS^ATIOX   OF    FEMALE   PELVIC   OEGAXS. 

presence  of  a  small  growth  in  the  anterior  or  j^osterior  parietes.  For 
the  purpose  of  enabling  the  inexperienced  to  arrive  at  what,  in  many 
instances,  is  valuable  information  in  this  respect,  I  have  devised  what 
may  be  called  the  hysterometer,  a  cut  of  which  is  here  given.  It 
consists  in  the  adaptation  of  two  uterine  jDrobes  to  each  other,  with 
handles  and  scale  for  measurement,  in  such  a  way  that  one  may  be 


Fig.  74. 


The  Hysterometer. 

introduced  into  the  bladder,  and  the  other  into  the  rectum.  Thus 
approximated  on  the  uterus,  as  represented  in  Fig.  75,  the  handles 
and  scale  may  be  so  arranged  as  to  make  the  measurement.  AVhen 
this  is  done  the  instrument  may  be  detached,  withdrawn,  and  the 
exact  thickness  of  the  uterus  is  ascertained.  If  we  wish  to  measure 
the  posterior  wall,  one  probe  is  introduced  into  the  cavity  of  tbe 
uterus,  and  the  other  into  the  rectum,  and  the  scale  and  handles  ad- 


LENGTH    OF    THE    CERVICAL    AND    UTERINE    CAVITIES. 


119 


justed,  the  measurement  taken,  and  the  instrument  withdrawn,  "When 
the  anterior  wall  is  to  be  aaieasured,  one  is  introduced  into  the  uterine 
cavity,  and  the  other  into  th-e  bladder.  In  this  way,  the  length  of  the 
uterus  and  the  thickness  of  the  walls  may  be  easily  measured. 

This  instrument  will  enable  us  to  be  much  more  accurate  in  our 
estimate  of  the  shape  of  th-e  uterus  than  any  other  means  we  can 
employ.  The  handles  of  the  probes  are  adapted  to  each  other  by 
means  of  a  slot,  running  from  one  end  to  the  other,  in  one  of  the 
handles,  while  the  other  is  of  a  size  to  fit  into  this  .slot  closed}^  knd 


Fig.  75. 


The  Method  of  Applying  the  Hjsterometer  for  Measuring  the  Thickness  of  the  Uterus. 


accurately.     The  scale  is  mad«  movable,  and  may  be  easily  adjusted 
after  the  probe  portions  of  the  instrument  are  in  their  projDer  place. 

In  cases  of  distortion  of  the  cavity  of  the  uterus,  or  where  there  is 
a  tumor  to  measure,  the  probes  wall  be  bent  in  different  directions, 
until  they  adapt  themselves  to  the  shape  of  the  parts.  In  consequence 
of  the  necessity  of  variance  in  the  curvature  of  the  probes  in  making 
such  measurements,  the  scale  can  serve  only  as  an  index  to  the  rela- 
tive position  of  the  two  probes,  and  cannot  be  relied  on  for  the  exact 
size  of  any  growth  or  other  cause  of  thickness  of  the  walls.     After 


120      INSTRUMENTAL   EXAMINATION   OF    FEMALE   PELVIC   ORGANS. 

having  adjusted  the  scale,  therefore,  and  observmg  the  figures,  we 
must  withdraw  the  instrument  and  readjust  by  the  scale,  and  then 
measure  the  distance  between  the  points  of  the  probes.  This  will 
give  us  the  true  measure.  Often  the  instrument  may  be  withdrawn 
without  loosening  it,  which  fact  will  facilitate  the  process  very  much. 
In  cases  of  retroversion  or  retroflexion,  when  we  wish  to  diagnos- 
ticate these  displacements  from  a  small  tumor,  which  they  sometimes 
very  closely  simulate,  one  of  the  probes  in  the  bladder,  so  curved  as 
to  follow  downward  and  backward  the  anterior  wall,  the  other  in  the 
uterine  cavity,  will  clearly  make  out  the  difference.  In  like  manner, 
only  with  reversed  curves,  and  one  probe  in  the  rectum,  the  tumor 
may  be  diagnosticated  to  be  present  or  absent. 

4,  Speculum. 

Since  the  speculum  has  come  into  such  general  use,  it  has  assumed 

a  variety  of  shapes,  and  been 
composed  of  quite  a  number 
of  different  sorts  of  materials. 
For  different  purposes  it  is 
convenient,  if  not  necessarj^, 
to  be  provided  with  different 
shapes,  sizes,  etc. ;  but  for  or- 
dinary use  we  ought  to  have 
three  different  sizes :  one 
small,  one  large,  and  the 
Higby's  Speculum.  "  ^      other  of  medium  size. 

The  bivalve,  trivalve,  and  Sims's  speculum  and  its  modifications 
are  the  most  useful  forms. 

Fig.  77. 


Fig.  76. 


Nolf  s  Speculum. 


Nelson's,  Nott's,  and  different  sizes  of  Higby's  are  popular  instru- 
ments. 


POSITION    OF    PATIENT    FOR    SPECULUM. 


121 


To  aid  us  in  getting  a  good  view  of  the  cervix,  we  may  draw  it  into 
view,  and,  if  necessary,  depress  it  somewhat  by  the  single  or  double 
tenaculum. 


Fig.  78. 


Nelson's  Speculum  (closed). 


Fig.  80. 


Fig.  79. 


Nelson's  Tenaculum. 


Nelson's  Speculum  (open). 


Position  of  Patient  for  Speculum. 

To  be  prepared  to  use  this  instrument  to  the  best  advantage,  our 
patient  sliould  be  placed  in  the  position  I  have  heretofore  described, 
viz.,  before  a  large  window,  through  which  as  much  daylight  should 

Fig.  81. 


Double  Tenaculum  Forceps. 


be  freely  admitted  as  possible.     The  better  light  the  better  view,  and 
unless  we  have  plenty,  we  cannot  be  certain  of  correct  results  in  our 


Fig.  82. 


Tenaculum  Forceps. 


examinations.     The  bed  and  patient  should  be  so  placed  that  the  light 
may  fall  straight  through  the  instrument  and  full  upon  the  parts  at 


122      IJS^STEUMENTAL    EXAMIXATIOX    OF    FEMALE    PELVIC    OEGANS. 

its  internal  extremity.  We  should  also  have  some  cotton-wool,  sweet 
oil,  and  a  couple  of  napkins,  together  with  the  dressing  forceps  I  have 
before  spoken  of. 

3fode  of  Using  the  Speculum. 

In  commencing  the  examination,  we  should  oil  our  speculum,  and 
our  middle  and  index  fingers.  Sitting  before  the  patient,  we  should 
introduce  the  index  finger,  and,  if  need  be,  the  middle  one  also,  to 
ascertain  the  position  of  the  cervix  uteri.  This  precaution  will  enable 
us  to  know  in  what  direction,  and  how  far,  to  introduce  the  siDCCulum. 
After  this  preliminary  examination,  the  forefinger  and  thumb  of  the 


Fig.  83. 


Speculum  introduced  (J^). 


left  hand  should  be  placed  upon  the  edge  of  the  labia,  one  upon  each 
side,  with  which  they  should  be  gently  separated ;  and  holding  the 
speculum  in  the  right  hand,  somewhat  like  a  pen,  we  may  introduce 
it  b}'-  the  guidance  of  the  thumb  and  finger  placed  as  above.  In  intro- 
ducing it,  we  should  push  it  forward  sufficiently  to  reach  the  cervix, 
and  direct  it  upward,  downward,  or  to  one  side,  as  we  may  have 
ascertained,  by  digital  examination,  to  be  the  position  of  tlie  os  and 
cervix. 


HOW   TO    FIND   THE    OS    UTERI. 


123 


How  to  Find  the  Os   Uteri. 

If  we  have  not  made  digital  examination,  we  may  use  our  probe, 
and  gently  push  the  parts  from  one  side  to  the  other,  turning  tlie 
speculum  in  different  directions  until  it  is  found.  If  the  neck  is  too 
large  to  enter  the  speculum,  we  may  spread  the  blades  still  more  until 
it  is  brought  into  full  view.  Most  frequentlj^  the  parts  are  covered  with 
some  sort  of  secretion,  and  we  should  always,  with  cotton-wool  or  lint, 
with  the  dressing  forceps,  remove  all  of  it,  so  that  the  naked  mucous 
membrane  alone  presents  itself  to  our  view.    Without  this  precaution, 


Fig.  84. 


Byford's  Dressing  Forceps. 


we  may  overlook  an  obvious  and  extensive  ulceration ;  for  as  the  parts 
are  covered  over  with  this  thick,  opaque  secretion,  it  either  completely 
hides  them  from  view  or  much  modifies  their  appearance.  I  have 
often  met  with  cases  which  I  have  observed  attentively,  for  the  pur- 
pose, if  possible,  of  detecting  ulcerations  without  this  step,  but  failed, 
until  the  cotton  was  used,  when  extensive  ulceration  appeared.  In- 
deed, I  never  think  of  coming  to  a  conclusion  of  any  kind  by  the  use 


Fig.  85. 


Sims's  Speculum. 


of  the  speculum  without  this  precautionary  measure.  By  this  means 
we  can  see  the  color,  size,  shape,  and  some  other  conditions  of  the 
parts,  and  the  color,  consistence,  and  derivation  of  the  secretions. 
When  the  mucus,  pus,  or  blood  comes  from  the  mouth  of  the  uterus, 
we  can  see  it  issuing  from  it.  The  shape  and  size  of  the  neck  and  os 
of  the  uterus  differ  in  different  individuals,  according  as  they  have 
been  impregnated  or  not. 

The  late  J.  Marion  Sims  has  instructed  us  in  a  different  method  of 
making  examinations.     He  prefers  a  table.     The  patient  is  placed  on 


124      INSTRUMENTAL    EXAMINATION   OF    FEMALE   PELVIC   ORGANS. 


the  left  side,  the  left  arm  under  and  behind  her,  the  legs  strongly 
flexed  upon  the  thighs,  and  these  again  upon  the  abdomen,  while  the 


Fig.  86. 


Sims's  Depressor. 


Fig.  87. 


right  knee  is  thrown  forward,  and  over  the  left  one  on  the  table; 
this  turns  the  patient  over  on  the  chest  and  partly  on  the 
abdomen.  In  this  position  his  speculum  is  introduced  by 
placing  the  forefinger  of  the  right  hand  in  the  concavity  of 
the  extremity  to  be  used,  and  the  finger  and  instrument  are 
introduced  together.  When  well  inserted,  the  perineum 
is  drawn  backward  and  the  instrument  is  given  to  an 
assistant  to  retain  in  place.  This  will  generally  expose 
the  cervix  uteri  completely  ;  but  if  it  does  not,  the  depressor 
is  placed  upon  the  anterior  wall,  and  this  latter  is  pressed 
out  of  the  way,  as  represented  in  Fig.  92.  Great  freedom 
of  examination  is  thus  obtained  in  most  cases.  Still,  if 
the  OS  uteri  is  not  seen  plainly,  it  is  seized  with  a  tenacu- 
lum and  drawn  toward  the  external  orifice.  Many  practi- 
tioners prefer  this  method  of  exposing  the  organ  for  all  ordi- 
nary purposes  of  inspection  and  application.  Dr.  Emmet  has 
modified  the  speculum  of  Dr.  Sims  by  constructing  it  in  a 
fashion  that  renders  it  self-retaining,  and  thus  does  away 
with  the  necessity  of  having  an  assistant.  Many  other  self- 
retaining  instruments  have  been  invented,  that  answer  an 
admirable  purpose,  among  which  I  mention  those  of  Fallen, 
of  St.  Louis,  Nott,  of  New  York,  and  Thomas,  Hunter, 
Studley,  Munde,  Gillette,  Erich,  etc.  Of  course  it  is  necessary 
to  have  the  patient  so  placed  that  the  light  will  fall  into  the 
dilated  vagina  and  on  the  cervix.  Dr.  Sims  drew  the  cervix  down, 
when   necessary,  by  means    of  a  tenaculum;  thus  facilitating  the 

Fig.  88. 


Tenac- 
ula. 


Nott's  Tenaculum  Forceps. 


examination,  and  enabling  the  practitioner  to  make  applications  or 
operations  upon  it  with  much  certainty. 


APPEARANCE    OF   THE   OS   AND    CERVIX    IN    THE   VIRGIN.       125 

Appearance  of  the  Os  and  Cervix  in  the  Virgin. 

The  virgin  uterus  is  small ;  the  cervical  end  is  nearly  round,  and 
terminates  in  a  truncated  extremity.     Through  the  speculum  it  does 

Fig.  89. 


Simon's  Speculum,  different  sizes. 


not  present  the  appearance  of  labial  projections^  and  the  os  is  either 
a  small  slit,  about  a  quarter  of  an  inch  long,  or  a  round  opening  into 


126      INSTRUMENTAL    EXAMIXATIOX    OF    FEMALE    PELVIC    ORGANS. 

the  middle  of  the  truncated  extremity.  It  is  about  large  enough  to 
admit  with  facility  the  end  of  a  female  catheter,  and  the  neck  projects, 
in  relief,  from  the  bottom  of  the  parts  exposed  by  the  speculum, 
something  like  half  an  inch. 

Appearance  of  the  Jlfultiparous  Uterus. 

The  appearance  of  the  multiparous  uterus  is  quite  different  from 
this;  the  cervix  terminates  in  labial  projections,  which  divide  its 
extremities  into  an  anterior  and  jDosterior  half,  and  it  does  not  project 


Simon's  Retractors.  Lever  for  Dilating  the  VaRiua  from  the  Side. 

with  SO  much  prominence  into  the  speculum.  The  os  is  re23resented 
by  the  cleft  between  these  labial  projections,  and  is  large  enough,  in 
many  instances,  to  admit  the  tip  of  the  index  finger. 

Appearance  in  the  Aged. 

In  the  aged  the  labial  projections  seem  to  have  atrophied  to  obliter- 
ation, and  the  speculum  shows  a  round  opening  in  a  funnel-shaped 
depression,  surrounded  by  the  walls  of  the  vagina. 


IIsDICATION   OF    MUCUS    IN    ABUNDANCE. 


127 


Exceptions  to  these  Appearances. 

Although  the  above  is  an  accurate  description  of  these  appearances 
under  the  different  circum&tances,  there  are  many  natural  deviations 
from  it. 

Color. 

The  color  of  the  mucous  membrane  covering  the  cervix,  and  enter- 
ing the  OS  uteri,  may  be  compared  to  that  of  the  inside  of  the  lips  of 
the  mouth,  a  pale  rose-red. 

Appearance  of  Secretion. 

The  parts  are  merely  lubricated,  not  smeared  or  inundated,  with 
mucus.     There  is  just  enough  of  this  secretion  to  keep  the  membrane 

Fig.  92, 


This  figruxe  represents  the  Axtion  of  the  Instruments  in  Sims's  method  of  Examining 

the  Uterus. 

moist,  but  not  enough  to  hide  the  surface  from  view.     I  speak  now 
of  the  cervix  uteri. 

Indication  of  Mucus  in  Abundance. 

An  aljundance  of  mucus  must  be  regarded  as  an  evidence  of  ex- 
citement; its  constant  and  persistent  abundance  as  an  evidence  of 
disease.  "  Remember,  that  in  spite  of  their  name,  it  is  not  the  busi- 
ness of  mucous  membranes  to  secrete  mucus ;  the  more  perfect  their 
condition,  the  more  favorable  the  surrounding  circumstances,  the  less 
they  do  so.  .  .  ,  The  greater  the  diminution  of  their  life,  the  greater 


128      INSTEUME^^TAL   EXAMINATION   OF   FEMALE   PELVIC   ORGANS. 

the  secretion."  The  more  disease,  the  greater  the  secretion,  until 
their  integrity  is  destroyed,  when  the  secretion  becomes  modified. 
The  source  whence  this  mucus  is  derived  will  show  the  point  of  dis- 
ease ;  if  it  comes  from  the  os  uteri,  the  disease  is  in  the  cavity  of  the 
cervix  or  body  of  the  uterus. 

Indication  from  Pus. 

It  is  extremely  doubtful  whether  pus  can  be  produced  by  a  mucous 
membrane  without  destruction  of  the  epithelium  at  least.  Temporary 
congestion  often  increases  the  amount  of  mucus  to  be  found  in  the 
vagina,  but  gives  origin  to  no  pus.  The  color  of  the  mucous  mem- 
brane, in  cases  of  congestion,  is  a  livid  or  a  dark  purple-red,  instead 
of  the  scarlet  of  abrasive  inflammation. 

Probe  and  Speculum  Conjointly. 

When  the  neck  of  the  uterus  is  exposed  in  the  speculum,  it  will 
often  be  profitable  to  use  the  probe.  If  proper  attention  is  paid  to 
appearances  under  the  use  of  the  probe,  much  information  may  be 
gained.  When  the  mucous  membrane  of  the  cavity  of  the  cervix  or 
body  is  inflamed,  it  is  generally  much  more  fragile  than  natural,  so 
that  it  bleeds  upon  slight  contact  with  the  end  of  the  probe.  In  cases 
where  the  inflammation  extends  to  the  cavity  of  the  uterus,  the  probe 
passes  the  os  internum  without  obstruction,  and  passes  farther  up 
than  natural  from  the  increased  size  of  the  cavity. 

Dilatation. 

By  properly  dilating  it,  we  ma}'-  subject  the  cavity  of  the  uterus  to 
a  digital  examination.  Sufficient  dilatation  may  be  effected  by  the 
use  of  tents  and  dilating  instruments  made  for  the  purpose.  The 
compressed  sponge,  laminaria,  tupelo,  and  slippery-elm  tents  are  all 
employed  as  means  of  dilatation.  The  sponge  tents,  as  prepared  and 
sold  by  instrument  makers,  are  of  various  sizes  and  lengths.  They 
are,  or  ought  to  be,  perforated  lengthwise,  carbolized,  and  covered  with 
a  lubricant  to  facilitate  their  introduction. 

The  sea-tangle  or  laminaria  and  the  tupelo  tents  should  also  be  of 
different  sizes  and  lengths,  smoothly  polished,  and  very  slightly  taper- 
ing. All  of  these  materials  can  be  made  in  a  flexed  form  to  suit  the 
curves  of  the  uterus.  When  an}''  of  these  tents  are  introduced  in  a 
dry  state  into  the  uterus,  they  absorb  the  moisture  of  its  cavity  and 
increase  in  size,  and  as  they  do  so  they  dilate  it. 

The  sponge  expands  more  rapidly  than  the  tupelo  or  laminaria 
tents,  and  is  less  powerful  in  its  dilating  influence.  There  is  not 
much  difference  in  these  respects  between  tlie  tupelo  and  laminaria 


DILATATION. 


129 


tents.     Perhaps  the  latter  expand  more  strongly  and  act  more  power- 
fully. 

As  the  sponge  dilates,  it  presents  a  rough  surface  to  the  mucous 
membrane,  and  to  a  considerable  extent  impairs  its  epithelial  cover- 


FlG.  93. 


Sponge  Tents. 

ing.  Serious  inflammatory  reaction  has  been  known  to  follow  the  use 
o'f  two  or  more  sponge  tents  in  immediate  succession.  The  surface  of 
the  tupelo  and  laminaria  tents  do  not  become  rough  as  they  expand, 

Fig.  94. 


Laminaria  Tent. 

and  consequently  are  not  as  likely  to  be  followed  by  injury  to  the 
mucous  membrane.  As  the  laminaria  becomes  moist  it  exudes  a 
mucilage  that  serves  as  a  protection  to  the  mucous  membrane. 

Fig.  95. 


Tupelo  Dilators  (hollow). 


Compressed  slippery-elm  bark  makes  a  less  powerful,  yet  very  useful 
dilator.     The  solid  tents  made  of  this  material  expand  to  twice  their 

9 


130       INSTRUMENTAL    EXAMINATION   OF    FEMALE    PELVIC   ORGANS. 

diameter  or  more,  in  from  one  to  two  hours,  when  placed  in  the  cervix 
— the  hollow  ones  in  much  less  time.  Their  rapid  and  comparatively 
safe  action  adapts  them  to  office  practice  when  we  only  seek  for  a 
moderate  but  rapid  dilatation.  When  the  cervico-uterine  canal  is 
tortuous,  the  smaller  elm  tents,  whether  curved  or  straight,  may  be 


Fig.  96. 


Compressed  Slippery-elm  Tents  (straight  and  curved). 


rendered  slightly  flexible  by  being  moistened  and  compressed  between 
the  blades  of  a  dressing  forceps  so  as  to  mash  or  break  some  of  the 
fibres. 

All  of  these  tents  should  be  w^ell  secured  by  having  a  strong  thread 
attached  to  them.     This  thread  enables  the  patient  or  practitioner  to 


Compressed  Slipperj^-elm  Tent  (hollow). 

remove  them  by  simple  traction,  and  does  away  with  the  necessity  of 
the  introduction  of  an  instrument  for  that  purpose. 

Tents  intended  to  widely  dilate  the  cervix,  of  whatever  kind,  should 
be  introduced  at  the  home  of  the  patient,  because  perfect  quietude  in 
bed  is  one  of  the  best  measures  to  prevent  the  untoward  effects  some- 
times caused  by  the  use  of  them. 

Siras's  position  is  the  most  convenient  for  the  introduction  of  the 
tent.  In  this  position  the  cervix  may  be  exposed  by  Sims's  specu- 
lum, drawn  slightly  forward,  and  fixed  by  the  uterine  tenaculum  or 


DILATATIOX. 


131 


a  small  vulsellum  (Fig.  87).  The  tent,  mounted  on  a  tent-bolder, 
or  seized  by  tbe  dressing  forceps,  is  passed  in  until  it  bas  entered 
tbe  OS  internum.  Tbe  upper  part  of  tbe  vagina  must  be  packed 
witb  cotton  placed  against  tbe  end  of  tbe  tent,  upon  wbieh  it  is 
made  to  rest.  This  will  secure  it  in  position,  otberwise  it  might  be 
more  or  less  completely  dislodged  and  thus  fall  short  of  its  fullest 
effects.  The  first  tent  should  be  of  a  size  that  will  permit  it  to  pass 
easily  into,  and  j^et  snugly  fit  tbe  cervical  cavity.  If  sponge,  it  will 
generally  require  about  twelve  hours  to  fully  expand,  and  should  the 


Fig.  I 


Fig.  99. 


Tent  mounted  on  Tent-holder. 


Molesworth's  Dilator. 


dilatation  not  be  sufficient  to  admit  the  finger,  the  vagina  and  cervical 
cavity  may  be  thoroughly  cleansed  with  carbolized  water,  and  a  second 
sponge  introduced  in  the  same  manner  as  the  first,  but  suiTounded  by 
small  slippery-elm  tents.  This  second  filling  must  be  large  enough  to 
fill  up  tbe  expanded  cavity,  and  secured  in  the  same  way  as  the  first. 
A  somewhat  longer  time  must  be  allowed  if  we  use  either  of  tbe  other 
kinds,  but  tbe  management  of  them  is  tbe  same  as  that  of  the  sponge. 
The  wounded  condition  of  the  cervical  mucous  membrane  caused  by 
tbe  sponge  tent  renders  it  very  susceptible  to  inflammation,  and  calls 


132      INSTRUMENTAL   EXAillNATION   OF   FEMALE   PELVIC   ORGANS. 

for  the  strictest  quiet  and  the  avoidance  of  all  co-operating  morbific 
causes.  The  same  condition  favors  the  absorption  of  septic  material, 
and  thus  exposes  the  patient  to  the  danger  of  septicsemia.  This  can 
only  be  avoided  by  strict  cleanliness. 

In  using  the  tupelo  and  laminaria  tents,  the  main  danger  consists 
in  the  liability  to  produce  inflammation  of  the  uterus,  which  may  be 
propagated  to  the  surrounding  tissue,  because  of  their  very  unyield- 
ing pressure  upon  the  submucous  structures  of  the  organ. 

From  these  considerations  the  student  will  learn  that  the  use  of 
tents  is  fraught  with  much  danger,  and  should  not  be  resorted  to 
except  under  such  circumstances  as  seem  to  render  them  indispensable 
to  correct  diagnosis  and  a  perfect  course  of  treatment.  The  patient 
should  be  kept  warm  and  in  the  recumbent  position  for  several  hours 
after  a  large  dilating  tent  has  been  used. 

There  are  other  means  of  dilating  the  uterine  cavity,  that  in  some 
cases  may  be  resorted  to  with  much  advantage,  especially  when  it  is 
desirable  to  perform  dilatation  in  a  short  time. 

Moles  worth's  dilator  (Fig.  99)  is  one  of  the  most  simple  and  effective 
instruments  for  this  purpose.  The  small-sized  dilator  may  be  made  to 
enter  the  unimpregnated  uterus,  and  when  expanded  by  filling  it  with 


Hanks'  Dilators. 


water,  under  strong  and  gradually  increasing  pressure  of  the  cylinder, 
it  will,  in  favorable  instances,  open  the  cervical  cavity  sufficient  to 
admit  the  second  size. 

By  succeeding  one  size  with  another  I  have,  in  less  than  an  hour, 
been  able  to  pass  my  finger  into  the  cavity  of  the  body.  The  uterus 
can  also  be  dilated  rapidly  by  hard  rubber  instruments,  a  very  con- 
venient form  of  which  is  Hank's  rapid  dilators. 

The  smallest  size  may  be  passed  into  the  cervix  bj^  slow  and  gradu- 
ally increasing  pressure.  It  may  be  succeeded  by  the  second,  and 
that  by  the  third,  and  so  on  until  the  cavity  will  admit  the  finger. 

When  the  uterus  is  especially  hard  and  undilatable,  the  gradual 
method,  consisting  of  the  use  of  tents,  is  the  proper  one  to  employ. 
When,  however,  the  mouth  of  the  cervix  is  softer  and  more  yielding, 


EXPLORATORY  CURETTING  OF  THE  UTERUS.        133 

the  rapid  method  is  preferable,  and  in  most  cases  Molesworth's  is  the 
instrument  to  be  used.  I  would  remind  the  student  that  great  care 
is  necessary  to  avoid  damage  from  the  use  of  any  of  these  instruments 
or  processes. 

The  object  in  dilating  the  uterine  cavity  is  to  enable  the  sense  of 
touch  to  discover  its  contents  and  condition.  Sometimes,  with  the 
patient  in  the  dorsal  position,  we  may  depress  the  uterus,  by  placing 
one  hand  above  the  symphysis,  sufficiently  to  bring  its  cavity  within 
reach  of  the  finger;  but  usually  it  will  be  necessary  to  draw  it  down  by 
a  tenaculum  or  vulsellum  until  the  finger  will  pass  up  to  the  fundus. 

Polypoid  or  submucous  tumors,  excrescences,  and  cancerous  ulcera- 
tion may  be  discovered  in  this  way  when  they  could  not  be  diagnosed 
with  precision  by  any  other  method  of  examination. 

Exploratory  Curetting  of  the  Uterus. 

When  it  is  inexpedient  or  undesirable  to  expand  the  uterine  cavity 
sufficiently  for  the  introduction  of  the  finger  (a  procedure  which  re- 
quires considerable  violence  unless  the  uterus  be  enlarged),  the  dull 
curette  may  be  used  for  its  exploration.     If  fungosities,  granulations, 


Probe  Curette. 


or  otherwise  disorganized  mucous  membrane  exist,  the  dull  curette 
will  detach  specimens  for  a  microscopic  examination  ;  if  there  be  no 
such  conditions  the  negative  result  will  also  be  valuable.  Thus,  in 
cases  of  enlargement  of  the  uterus  with  hemorrhage,  when  we  are  in 
doubt  as  to  whether  we  have  to  deal  with  cancer,  sarcoma,  mucous 


^^^^^g^^^^^^ 


Thomas's  Wire  Curette. 

polypus,  or  an  interstitial  fibroid,  the  dislodgment  of  specimens  gives 
evidence  of  the  first  three  conditions,  the  absence  of  anything  to  be 
dislodged  is  of  diagnostic  value  in  the  latter. 

A  loop  of  bent  copper  wire  with  the  ends  twisted  into  a  stem  and 
covered  with  a  small  rubber  tube  may  serve  for  this  purpose.  There 
is  a  dull  curette  in  the  market  made  to  imitate  a  uterine  probe  bent 
at  the  end  into  a  loop.  Thomas's  wire  curette  is  also  a  very  popular 
instrument. 

I  have  had  one  constructed  something  after  the  pattern  of  Sims's 
sharp  curette,  but  perfectly  dull,  and  quite  strong,  although  flexible 


134      INSTRUMENTAL    EXAMINATION    OF    FEMALE    PELVIC   ORGANS. 

in  the  shank,  with  the  end  in  view  of  being  able  to  use  considerable 
force  without  doing  injury.  We  may  obtain  with  it  some  information 
as  to  the  size  of  the  uterine  cavity,  the  smoothness,  roughness,  or  fria- 
bility of  its  mucous  surface,  and  the  firmness,  sensitiveness,  and  con- 
tour of  the  uterine  walls,  and  thus  make  of  it  a  sort  of  substitute  for 
the  finger.  A  weaker  shank  would  give  unreliable  information,  while 
a  finer  loop  might  produce  unpleasant  or  dangerous  results.  I  con- 
sider this  curette  so  safe  when  properly  used,  that  I  occasionally 
employ  it  in  office  diagnosis,  but  would  be  afraid  to  use  any  of  the 
others  with  the  same  freedom.  Two  larger  sizes  are  manufactured  for 
(1)  diseases  involving  enlargement  of  the  uterus  and  (2)  retained 
secun dines  in  abortion,  which  are  more  useful  as  therajjeatic  agents, 
but  less  so  as  diagnostic.  A  hollow  compressed  elm  tent.  Hanks'  or 
Peaselee's  dilators,  or  a  flexible  male  bougie  will  sufficiently  dilate 

Fig.  103. 


Byford's  Finger  Curette. 


the  cervix  in  a  few  minutes  for  the  smallest  size,  unless  the  uterus  be 
too  small  to  recjuire  exploratory  curetting.  A  curette  should  not  as  a 
rule  be  used  if  there  be  much  uterine  or  peri-uterine  tenderness,  nor 
during  menstruation,  nor  during  jDregnancy. 


The  Use  of  the  Female  Catheter. 

The  female  catheter  usually  passes  in  a  slight  curve  backward  and 
upward  behind  the  pubis  toward  the  neck  of  the  bladder.  When  the 
urethra  is  dilated  or  sacculated  the  end  of  the  catheter  passes  readily 
in  almost  any  backward  direction,  and,  instead  of  taking  its  own 
course  into  the  bladder,  must  be  carefully  guided.  In  case  of  prolapse 
of  the  neck  of  the  bladder  the  instrument  passes  back  toward  the 
recto-vaginal  promontory  away  from  the  pubis. 

When  the  parts  cannot  or  ought  not  to  be  exj^osed  the  catheter  can 
be  introduced  by  the  touch.  The  index  finger  is  placed  along  the 
urethral  ridge  between  the  urethral  notches  and  drawn  forward  until 
the  depression  at  its  lower  end,  and  just  external  to  the  pubic  arch, 
corresponding  to  the  meatus,  is  recognized,  and  the  point  of  the  cath- 
eter is  slipped  along  the  finger  into  it.     Its  withdrawal  should  be  slow 


THE    URETHRAL   SPECULUM    AND    EXDOSCOPE.  135 

that  the  lower  portion  of  the  bladder  may  have  time  to  be  em23tied. 
The  finger  should  be  pressed  over  the  mouth  of  the  instrument  as 
soon  as  the  other  end  has  passed  out  of  the  bladder  into  the  urethra, 
for  the  purpose  of  retaining  the  last  drops,  and  keeping  them  from 
running  out  on  the  bedclothes,  and  also  of  preventing  the  suction  of 
air  into  the  bladder  by  an  inopportune  inspiration  or  movement  of 

Fig.  104.  Fig.  105. 


Sims's  Sigmoid  Catheter,  Self-retaining.  Goodman-Skene's  Self-Retaining  Catheter. 


the  patient.     Winckel  warns  against  depressing  the  outer  end  of  the 
catheter  too  much  for  fear  of  the  entrance  of  air-bubbles. 

Sims's  sigmoid  catheter  (Fig.  104)  and  the  Goodman-Skene's  self- 
retaining  catheter  (Fig.  105)  are  useful  when  it  becomes  necessary  to 
keep  the  bladder  drained,  as  they  remain  in  place. 

The  Urethral  Speculum  and  Endoscope. 

In  rare  instances  it  become  necessary  to  inspect  the  mucous  mem- 
brane of  the  bladder.  The  necessary  dilatation  of  the  urethra  may 
be  accomplished  by  using  almost  any  of  the  uterine  or  urethral  dila- 
tors to  begin  with,  and  the  fingers  afterward.  (See  "  Palpation  of  the 
Interior  of  the  Bladder,"  Chapter  II.)  The  little  finger  can  thus  be 
got  into  the  bladder  without  doing  much  damage.  Dilatation,  to  the 
extent  of  admitting  a  large  index  finger,  or  Simon's  largest  dilator, 
has  frequently  been  followed  for  a  long  time,  sometimes  permanently, 
by  incontinence  of  urine.  The  way  to  avoid  such  an  accident  is  to 
commence  with  small  dilators,  and  dilate  very  gradually,  consuming 
from  half  to  one  hour  for  the  extreme  dilatation.  Incontinence  has 
usually  been  the  result  of  haste  or  carelessness.  An  anaesthetic  must 
of  course  be  administered. 

A  small  test-tube  may  be  made  to  answer  the  purpose  of  a  urethral 
speculum,  and,  with  a  small  rhinoscopic  mirror  and  reflector,  also,  of 
an  endoscope  for  the  inferior  portion  of  the  bladder.  Skene,  Barnes, 
A.  R.  Jackson,  and  others  have  invented  special  specula,  but  the 
dilated  urethra  can  usually  be  pretty  well  inspected  by  stretching 
open  the  lower  end  with  the  finger  or  blades  of  a  dressing  forceps. 
Skene's  endoscope  is  a  valuable  instrument  for  occasional  use.  By 
first  distending  the  bladder  with  air,  as  recommended  by  Rutenberg, 
quite  a  satisfactory  exploration  can  be  made.  Moderate  distension  of 
the  bladder  with  air  does  not  seem  to  add  much  to  the  danger  of  the 
examination,  although  it  must  be  remembered  that  thorough  instru- 


136      INSTRUMENTAL   EXAMINATION   OF    FEMALE   PELVIC   ORGANS. 

mental  examinations  of  this  kind  are  seldom  entirely  without  danger. 
Moderate  mucous  irritation,  and  even  inflammation,  have  frequently 
followed,  cellulitis  occasionally,  and  in  two  instances  death. 

The  mucous  membrane  of  the  collapsed  bladder  appears  of  a  dirty 
grayish  red  through  the  endoscope,  but  when  distended  with  air,  a 
brighter  red.     The  slits  corresponding  to  the  urethral  orifices  cannot 


Skene's  Urethral  Endoscope. 


usually  be  seen  until  entered  by  a  probe  or  catheter.  If  the  surface 
be  wiped  off  and  the  walls  of  the  bladder  pressed  so  as  to  produce 
lateral  traction,  the  trickling  urine  sometimes  indicates  the  exact  loca- 
tion of  the  orifices. 

Catheterization  of  the  Ureters. 

Catheterization  of  the  ureters  was  first  performed  by  Simon'=*  and 
after  him  by  others.     The  object  in  view  was  usually  to  draw  urine 


Fig.  108. 


gi';*";^tej!"'.^ 


''  /^,'JM'.JiVJ!rff^ 


Simon's  Uretral  Catheter. 


from  one  kidney  for  examination,  in  cases  of  suspected  unilateral 
,yelitis  and  pyo-nephrosis. 

The  uretral  catheter  is  small,  long  and  straight,  with  a  longer  and 
more  gentle  curve  on  the  end  than  the  female  urethral. 


*  Chirurgie  der  Nieren. 


CATHETEEIZATION   OF   THE    URETEES.  137 

There  are  four  ways  of  catheteriziiig  the  ureter : 

1.  By  the  vesical  touch. 

2.  By  vaginal  inspection. 

3.  By  vesical  inspection. 

4.  By  the  vaginal  touch. 

1.  Simon  made  use  of  the  vesical  touch  through  the  dilated  urethra. 
The  inter-uretric  ligament,  which  connects  them,  is  one  inch  beyond 
the  sharp  border  of  the  mouth  of  the  bladder,  and  the  uretral  ori- 
fices about  half  an  inch  to  either  side  of  the  median  line.  They  are 
felt  as  slight  elevations  instead  of  depressions,  over  one  of  which  the 
finger  is  laid  as  the  catheter,  guided  by  the  touch,  is  pushed  into  it. 
(See  Chapter  II,  Fig.  58.)  The  handle,  or  external  end  of  the  catheter 
must  of  course  be  raised  and  carried  a  little  to  the  opposite  side,  as 
the  ureter  takes  the  diagonal  direction.  It  is  possible  to  pass  it  to  the 
pelvis  of  the  kidney.* 

2.  Pawlickf  exposes  the  anterior  vaginal  wall  in  the  Sims's  position, 
and  introduces  the  uretral  catheter  under  the  direction  of  the  eye. 
The  upper  end  of  the  urethra  is  marked  by  a  small  prominence  not 
far  from  an  inch  behind  the  meatus  in  the  median  line.  From  this 
prominence  two  diverging  ridges  run  backward  and  are  joined  by 
slight  furrows.  The  sj)ace  thus  included  corresponds  to  the  trigone 
at  whose  posterior  angles  the  mouths  of  the  ureters  are  to  be  sought. 
The  catheter  is  introduced  so  that  its  end  turns  back  against  the  base 
of  the  bladder  and  followed  by  the  prominence  it  produces  on  the 
anterior  vaginal  wall.  As  the  exact  point  of  opening  of  the  ureters  is 
difficult  to  strike,  he  is  careful  to  make  the  direction  of  the  catheter 
correspond  to  the  direction  of  the  ureter,  so  that  it  will  more  easily  slip 
into  the  minute  orifice  when  it  passes  over  it.  A  thorough  knowledge 
of  the  anatomy  of  the  parts,  and  considerable  gynecological  experience 
is  necessary  to  execute  this  difficult  although  simple  manoeuvre.  The 
limitation  of  the  motion  of  the  catheter  and  the  trickling  of  urine 
announce  the  successful  passage. 

3.  Inspection  of  the  uretral  orifice  requires,  of  course,  extreme  dila- 
tation of  the  urethra  and  the  introduction  of  a  speculum  into  the 
bladder  so  as  to  bring  the  orifice  of  the  ureter  into  view.  The  only, 
and  the  great,  difficulty  lies  in  getting  a  view  of  the  orifice.  Some- 
times the  urine  can  be  seen  issuing  from  one  ureter  by  pressing  the 
speculum  blade  over  the  other.  Arthur  Lewer  thus  describes  his 
method  of  exposing  the  orifices:  J  "The  urethra  is  dilated;  then  one 
piece  of  Bryant's  rectal  speculum  is  passed  along  the  urethra  into  the 

*  For  a  more  detailed  account  of  the  method  see  Winckel's  Diseases  of  the  Female 
Urethra  and  Bladder. 

f  Archiv  fiir  Gynekologie,  vol.  xviii. 

J  London  Lancet  (American  Reprint),  January,  1887,  p.  27. 


138       INSTRUMENTAL    EXAMINATION    OF    FEMAF.E    PELVIC    ORGANS. 

bladder  and  so  placed  that,  seen  from  the  front,  it  occupies  one  lateral 
half  of  the  urethra  and  bladder  beyond.  When  in  this  position  the 
speculum  divides  the  bladder  into  two  compartments ;  for  example, 
supposing  the  speculum  occupies  the  right  lateral  half  of  the  urethra 
and  bladder,  then  the  orifice  of  the  left  ureter  is  in  view."  With  the 
orifice  in  view  the  introduction  of  the  catheter  can  be  accomplished 
by  sight. 

4.  The  simplest  of  all  methods,  however,  is  to  find  the  interuretric 
ligament  or  else  the  junction  of  the  ureter  and  the  trigone  by  vaginal 
indagation,  according  to  the  methods  explained  in  Chapter  II.  (Palpa- 
tion of  the  Ureters).  The  jDoint  of  the  catheter  is  then  introduced  into 
the  bladder  and  turned  down  upon  the  trigone  where  it  can  be  felt  by 
the  vaginal  finger.  With  the  end  of  the  catheter  on  the  vesical  surface 
of  the  vesico-vaginal  septum,  and  the  finger  on  the  vaginal,  we  should 
have  but  little  trouble  in  getting  the  inter-uretric  ligament  between 
them,  and  tracing  it  to  the  uretral  orifices,  which  are  about  an  inch 
apart.  The  direction  of  the  ureter  having  been  determined  by  vaginal 
palpation,  the  catheter  is  given  a  corresponding  direction,  and  guided 
as  far  as  possible  up  the  ureter  by  the  vaginal  finger. 

In  attempting  this  manoeuvre  for  the  first  time  an  anaesthetic  should 
be  given,  and  great  care  be  taken  to  keep  the  end  of  the  slightly  curved 
catheter  upon  the  base  of  the  bladder,  and  to  avoid  using  force  or 
poking  about  too  freely.  As  the  bladder  walls  yield  to  pressure  there 
is  some  danger  of  thinking  that  the  catheter  or  probe  is  a  couple  of 
inches  up  the  ureter  when  it  is  only  in  the  bladder,  and  of  poking  it 
into  or  through  the  walls  or  against  inflamed  pelvic  tissues.  It  should 
be  felt  by  the  vaginal  finger  to  pass  under  the  broad  ligament. 
Moderate  dilatation  of  the  urethra  including  the  neck  of  the  bladder 
renders  the  introduction  easier.  If  folds  of  the  bladder  interfere,  a 
few  ounces  of  water  may  be  injected  into  it.  The  end  of  the  catheter, 
being  on  the  finger,  can  be  guided  with  great  delicacy,  and  there  is  not 
so  much  danger  of  doing  harm  as  in  Pawlick's  method,  which  requires 
either  sufficient  pressure  upon  the  base  of  the  bladder  for  the  end  of 
the  instrument  to  produce  a  projection  on  the  septum,  or  else  a  nice 
judgment  in  determining  when  the  instrument  arrives  at  the  point  in 
the  bladder  opposite  that  marked  by  the  eye  ujDon  the  vaginal  wall; 
nor  as  in  Simon's  and  Lewer's  methods.,  which  require  considerable 
rough  handling  of  the  urethral  walls. 

As  it  is  hardly  possible  to  catheterize  or  probe  the  ureter  in  every 
instance,  it  is  better  to  desist  after  a  few  unsuccessful  attempts,  and 
wait  for  another  opportunity. 

General  Manner  of  Conducting  an  Examination  in  Making  a  Diagnosis. 

Having,  from  the  history  of  the  case,  located  the  disease  in  some 
portion  of  the  pelvis,  and  having  determined  that  an  examination 


GENERAL    MANNER   OF    CONDUCTING   AN    EXAMINATION.       139 

must  be  made,  we  first  resort  to  a  digital  exploration.  If  the  rectum 
seems  to  be  the  seat  of  the  trouble,  we  should  put  the  patient  on  her 
side  with  the  knees  drawn  up,  and  explore  the  rectum  and  if  necessary 
the  pelvic  interior  as  much  as  possible  through  the  anus.  When  the 
patient  is  a  young  virgin  such  an  exploration  maybe  made  to  indicate 
where  the  disease  resides,  and  sometimes  may  do  away  with  the  neces- 
sity of  a  vaginal  examination.  If,  however,  she  have  had  previous 
vaginal  examinations,  or  have  borne  children,  and  have  symptoms 
that  leave  no  doubt  as  to  the  existence  of  pelvic  disease  outside  of  the 
rectum,  she  should  be  put,  preferably,  in  the  dorsal  position  and  exam- 
ined per  vaginam.  In  the  unmarried  the  finger  will,  in  passing,  recog- 
nize the  condition  of  the  hymen  and  amount  of  contraction  of  the 
orifices.  In  the  childbearing  woman  it  is  sufficient  at  first  to  pass  the 
finger  slowly  so  as  to  be  able  to  recognize  the  amount  of  relaxation  or 
contraction  of  the  orifices,  sensitiveness  or  flabbiness  of  the  mucous 
membrane  and  lower  portions  of  the  urethra  and  rectum.  If  extensive 
alteration  be  found  the  parts  may  be  immediately  inspected ;  if  not, 
the  manipulations  about  the  vulva  are  better  left  until  the  close  of 
the  examination,  that  irritation  or  contraction  of  the  sensitive  parts, 
as  well  as  disagreeable  impressions  upon  the  patient,  may  not  be  pro- 
duced at  the  outset.  My  practice  is  to  note  the  general  condition  of 
the  vulvo-vaginal  entrance  as  I  introduce  the  finger,  and  to  press  the 
finger  end  into  the  tissues  as  I  withdraw  it  after  the  palpation  of  the 
deeper  structures,  but  to  leave  the  inspection,  vaginal  eversion  and 
grasping  of  the  perineum  between  the  fingers  in  the  rectum  and  the 
others  over  the  skin  and  vulvo-vaginal  surface,  until  after  the  speculum 
is  withdrawn. 

If  a  digital  exploration  through  the  rectum  be  desirable,  it  may  be 
made  as  soon  after  the  vaginal  examination  as  the  hands  can  be 
cleansed  or  after  the  speculum  has  been  used.  Examinations  of  the 
urethra  should  usually  be  delayed  until  toward  the  end,  as  they  are 
apt  to  cause  irritation  and  unnerve  the  patient. 

As  the  instrumental  examination  gives  us  but  a  small  part  of  our 
information,  it  is  well,  before  using  it,  to  determine  as  nearly  as  possible 
the  position  and  condition  of  each  pelvic  organ  by  the  various  forms 
of  intra-pelvic  and  bimanual  palpation.  The  probe  or  sound  can 
seldom  give  us  any  accurate  information  as  to  the  position  of  the 
organ  unless  the  cervix  is  turned  forward,  or  unless  the  uterus  is  fixed 
by  adhesions;  hence  in  ordinary  cases  I  wait  until  I  have  exposed 
the  OS  by  the  speculum  before  using  it.  The  speculum  usually  turns 
the  axis  of  the  uterus  so  that  the  sound  or  probe  may,  unless  con- 
tra-indications  exist,  be  introduced  with  safety  until  it  meets  with 
resistance. 

The  experienced  gynecologist  can  usually  determine  by  the  digital 
exploration  the  appearance  to  be  presented  through  the  speculum,  and 


140      INSTRUMENTAL   EXAMINATION   OF   FEMALE   PELVIC   ORGANS. 

needs  the  instrument  chiefly  for  treatment.  The  general  practitioner 
will  require  it,  however,  to  diagnose  the  amount  and  character  of 
uterine  ulceration  and  congestion  and  the  discharge.  The  character  of 
ulceration,  whether  simple  erosion,  granulating  or  dissecting;  the 
color,  whether  normal,  pale,  dark  red  or  dark  blue;  the  shape  of  the 
OS  and  labia,  and  position  of  deposits  or  enlargements,  etc.,  should  be 
accurately  noticed. 

The  condition  of  the  vaginal  mucous  membrane  should  also  be  noted. 

In  pregnancy  and  in  some  cases  of  pelvic  disease  it  is  altered  in 
color  to  correspond  with  the  cervix.  In  cases  of  uterine  disease  it  is 
altered  in  color  either  independent  of  the  cervix,  or  is  not  altered  as 
much  as  the  cervix,  if  at  all. 

An  examination  of  the  interior  of  the  bladder,  or  a  dilatation  of  the 
uterine  cavity,  or  in  fact  any  long-continued  manipulation,  should 
be  avoided  if  possible  at  a  first  examination,  or  at  the  ofiice.  Our 
endeavor  must  be  to  benefit  the  patient,  and  to  do  that  we  should 
study  to  avoid  doing  any  harm.  For  particulars  as  to  examinations 
see  Chapters  II.  and  III. 


CHAPTER    Y. 

DISEASES  AND  ACCIDENTS  OF  THE  LABIA  AND  PERINEUM. 

Adhesion  of  the  labia,  and  consequent  occlusion  of  the  vagina, 
sometimes  occurs  in  infancy,  or  early  childhood,  as  well  as  in  adult 
life.  The  adhesions  of  infancy  are  so  feeble  and  easily  broken  up, 
that  they  may  be  considered  a  trifling  affair.  Upon  examining  the 
parts,  it  will  be  found  that  there  is  no  development  of  adhesive  tissue, 
but  the  mucous  membrane  of  the  two  sides  is  merely  glued  together 
b}'^  the  mucus  accumulating  and  drying  between  the  parts,  when  in 
close  contact,  from  want  of  cleanliness.  The  vaginal  orifice  is  closed  up 
to  the  urethra  above,  and  down  to  the  fourchette  below.  The  treat- 
ment consists  in  separating  the  labia,  by  forcibly  pressing  each  in 
opposite  directions,  until  the  adhesion  gives  way,  and  waehing  and 
oiling  them  once  a  day  afterwards  to  keep  them  from  adhering  again. 
Should  we  not  be  able  to  separate  them  in  this  way,  the  point  of  a 
silver  catheter  may  be  passed  down  so  as  to  effect  it.  There  will  be  no 
need  of  any  other  instruments  in  the  case. 

On  one  or  two  occasions  I  have  seen  firm  tissual  cohesions  of  the 
labia  in  childhood  as  the  effect  of  ulcerative  vulvar  inflammation. 
This  form  of  adhesions  may  be  so  firm  as  to  require  the  use  of  the 
knife.  They  are,  however,  always  superficial,  and  we  may  generally 
introduce  a  bent  probe  or  director  behind  the  adhesions  from  above. 
When  this  is  the  case,  it  is,  I  believe,  the  best  plan  to  separate  them, 
by  drawing  the  bent  director  through  the  adherent  part.  The  same 
care  as  in  the  infant  will  prevent  them  from  adhering  again. 

The  most  grave  labial  adhesions  we  meet  are  in  the  adult,  as  the 
effect  of  neglected  inflammation  of  the  vulva  after  childbirth.  They 
may  entirely  close  the  vaginal  orifice  by  the  coaptation  of  the  entire 
inner  surfaces  of  the  labia.  I  have  met  with  more  than  one  instance 
in  which  the  hairy  margins  of  the  labia  were  so  nicely  adjusted  to  each 
other,  that  it  was  difficult  to  distinguish  the  point  of  original  separa- 
tion, from  the  posterior  commissure  to  the  urethral  orifice,  and  the 
finest  probe  would  not  reach  the  vagina  anywhere.  The  depth  of  the 
adhesion  may  be  very  great,  involving  much  of  the  vaginal  cavity. 

These  cases  are  very  embarrassing,  and  are  seldom  perfectly  reme- 
died. It  is  decidedly  the  best  plan  not  to  interfere  with  them  until 
the  menstrual  accumulation  fills  up  all  the  vaginal  cavity  remaining 
inadherent,  and  then  our  object  should  be  to  reach  the  accumulation 
with  a  small  trocar  as  near  the  middle  of  the  adherent  parts  as  pos- 
sible.    Placing  our  patient  in  the  lithotomy  position,  the  catheter 


142       DISEASES   AND    ACCIDENTS    OF    THE    LABIA    AND    PERINEUM. 

should  be  introduced  into  the  urethra,  the  urine  all  drawn  off,  and  the 
urethra  held  as  near  the  symphysis  pubis,  or  as  far  from  the  middle 
line  of  the  vagina,  as  practicable.  The  catheter  should  be  thus  held 
by  an  assistant,  while  the  forefinger  of  the  left  hand  should  be  placed 
in  the  rectum.  With  this  preparation  we  may  safely  introduce  the 
trocar  into  the  collection  of  fluid  as  felt  by  the  finger.  The  fluid  being 
drawn  off,  the  outer  extremity  of  the  perforation  may  be  increased  by 
laceration  as  far  as  may  be  desired,  and  as  deeply  as  the  surgeon 
may  consider  it  safe.  The  whole  cavity  should  be  thoroughly 
cleansed  by  a  syringe  with  soap  and  water  and  the  opening  may  be 
maintained  by  a  glass  plug.  If  the  opening  is  superficial,  the  treat- 
ment will  not  be  protracted  ;  but  if  it  is  deep,  it  will  be  tedious.  It 
should  be  continued  until  all  danger  of  closure  is  past,  and  it  will  be 
best  to  keep  the  patient  under  our  supervision  for  sometime  after  this 
appears  to  be  the  case. 

Wounds. 

The  labia  are  sometimes  wounded  by  external  violence  and  some- 
times torn  during  labor.  When  the  wound  is  deep  enough  to  reach 
the  bulb  of  the  clitoris,  alarming  and  sometimes  fatal  hemorrhage  is 
the  result.  Professor  Meigs  gives  an  instance  of  great  hemorrhage 
from  these  parts  in  a  woman  who  had  fallen  upon  a  chair  so  as  to  cut 
through  one  of  the  labia.  A  case  of  fatal  hemorrhage  was  caused 
in  this  city  about  four  years  since,  in  the  following  manner,  as  well  as 
it  could  be  learned  from  a  legal  investigation :  A  drunken  husband 
returned  home  late  at  night,  and,  as  was  his  wont  under  such  circum- 
stances, beat  and  kicked  his  wife,  who  was  probably  also  inebriated. 
He  kicked  her  with  great  violence  in  the  genitals,  and  the  square-toed 
heavy  boot,  in  penetrating  the  pelvis,  had  cut  off  one  labium  and 
deeply  wounded  the  other.  In  six  or  eight  hours  after  the  occurrence 
the  woman  Avas  found  dead,  with  such  copious  effusion  of  blood  from 
the  wounds  as,  in  the  opinion  of  the  examining  jury,  to  account  for  the 
fatal  result.  I  saw  a  case  many  years  ago,  where  the  patient  was 
wounded  by  a  knife  in  one  labium  so  as  to  cause  very  profuse  hem- 
orrhage. 

As  hemorrhage  is  the  important  effect  of  these  wounds,  our  efforts 
should  be  directed  to  its  suppression.  The  bleeding  part  should  be 
pressed  by  the  hand  firmly  against  the  pubic  ramus  of  the  side  upon 
which  it  is  situated  until  temporarily  arrested,  when  an  elastic 
air-bag  or  plug  of  oiled  cotton  or  lint  may  be  introduced  to  fill  up  the 
vagina,  and  a  hard  compress  placed  and  held  firmly  by  bandages,  so 
as  to  press  the  wounded  part  between  the  two.  When  wounds  of  the 
labia  are  large  and  gaping,  the  hair  should  be  removed,  and  tlie  wound 
treated  according  to  ordinary  rules  for  external  wounds.  The  rents 
occurring  in  labor  do  not,  in  the  great  majority  of  cases,  require  any 
special  treatment,  cleanliness  and  quiet  being  all  that  is  required. 


VARICES   OF   THE    LABIA    AND    VULVA.  ]43 

Sanguineous  Infiltration. 

During  labor,  when  the  parts  are  stretched  to  their  utmost  extent, 
some  of  the  arterial  twigs  occasionally  give  way  and  extravasate  the 
blood  in  the  loose  structure  of  one  labium.  The  infiltration  usually 
shows  itself  after  the  child  has  been  delivered;  but  sometimes,  before 
the  head  has  passed,  the  swelling  becomes  very  great,  and  proves 
an  obstacle  to  its  expulsion.  When  this  last  is  the  case,  the  blood 
is  effused  from  a  large  branch  of  the  pubic  artery,  and  the  forcible 
injection  into  the  tissues  is  so  extensive  as  to  fill  a  large  part  of  the 
space  between  the  vagina  and  the  pelvic  walls.  This  is  a  very  seri- 
ous state  of  affairs,  and  calls  for  prompt  and  judicious  interference. 
I  once  saAV,  in  consultation,  a  case  of  this  kind,  so  extensive  as  to  ar- 
rest labor  for  several  hours.  These  effusions,  however,  do  not  always 
call  for  surgical  treatment,  but  when,  as  in  the  case  here  alluded  to, 
the  effusion  is  extensive,  we  must  make  a  free  incision  in  the  inner 
surface  of  the  labium  and  allow  the  blood  to  escape ;  if  it  is  coagulated, 
we  should  introduce  the  fingers  and  dislodge  it.  Water- dressing,  some 
evaporating  lotion  or  cooling  discutient  will  be  sufficient,  and  absorb- 
tion  will  be  effected  in  from  one  to  four  weeks.  Suppuration  occasion- 
ally, I  think  not  frequently,  is  excited  by  a  small  amount  of  effusion. 
This  should  be  treated  as  an  abscess.  If  the  amount  of  blood  is  great 
and  the  parts  are  tensely  distended  even  after  the  child  is  expelled,  it 
is  better  to  liberate  it  by  incision,  for  fear  of  sloughing  or  extensive 
suppuration  and  serious  damage. 

Varices  of  the  Labia  and  Vulva. 

This  condition  of  the  vulva  may  be  of  greater  or  less  extent.  Gen- 
erally the  varicosities  are  scattered  about  on  the  inner  side  of  the 
greater  labia  ;  sometimes  only  one  or  two  exist  of  any  size,  but  occa-- 
sionally  one  labium  is  permeated  by  large  blue  veins  in  every  direc- 
tion until  they  seem  to  have  almost  entirely  replaced  the  other  tissue. 

When  the  venous  enlargement  is  great  there  is  danger  of  rupture 
and  profuse  hemorrhage,  even  enough  to  bring  about  fatal  results. 
The  veins  are  especially  large  during  pregnancy,  and  if  wounded  re- 
quire prompt  and  energetic  treatment.  For  the  emergency,  pressure 
on  the  point  of  rupture  will  enable  us  to  immediately  arrest  the 
hemorrhage.  The  ligature,  however,  will  be  necessary  to  secure  the 
patient  from  an  immediate  repetition  of  the  accident.  This  should 
be  applied  so  as  to  completely  control  the  loss.  The  radical  cure  re- 
quires the  obliteration  of  the  veins,  effected  in  the  same  manner  as 
elsewhere,  by  injection  Avith  the  persuljDhate  of  iron,  ligating  with  or 
without  pins,  etc.  A  radical  cure  should  never  be  attempted  in  the 
absence  of  pregnancy,  unless  demanded  by  some  great  emergency. 


144       DISEASES    AND    ACCIDENTS    OF    THE    LABIA    AND    PERINEUM. 

(Edema. 

The  distensible  nature  of  the  structure  of  the  labia  renders  them 
liable  to  great  oedematous  infiltration  in  cases  of  general  dropsy. 
Ordinarily,  such  distension  is  a  matter  of  trifling  importance,  but  the 
supervention  of  labor  at  a  time  when  they  are  very  largely  swollen  is 
often  an  embarrassing  condition.  They  are  sometimes  so  swollen  as 
to  occlude  the  vaginal  entrance,  and  yield  only  after  protracted  eflforts, 
and  even  then,  sometimes,  only  after  one  of  them  has  been  more  or 
less  torn.  When  excessive  oedema  is  discovered  before  the  head 
presses  upon  the  external  parts,  or  even  then,  no  time  should  be  lost 
in  taking  measures  to  lessen  their  size.  This  may  be  best  done  by 
everting  first  one  and  then  the  other,  and  making  from  ten  to  twenty 
small  punctures  through  the  mucous  membrane  only.  A  very  sharp- 
pointed  knife,  taken  between  the  thumb  and  finger  of  the  right  hand, 
so  as  to  show  only  about  the  eighth  of  an  inch,  is  the  best  instrument. 
Several  quick,  smart  strokes  with  the  instrument  thus  held,  suffice  for 
the  operation.  The  serum  exudes  from  the  punctures,  and  in  half  an 
hour  the  swelling  is  very  much  reduced. 

Phlegmon. 

Abscesses  in  the  labia  are  apt  to  occur  in  three  different  forms.  The 
first  is  common  phlegmonous  inflammation,  occurring  in  the  central 
part  of  one  labium,  very  rarely  in  both.  The  heat,  swelling,  and  pain 
are  very  great,  and  the  inflammation  runs  its  course  quite  rapidly, 
generally  suppurating  and  discharging  in  from  six  to  eight  days.  This 
form  of  inflammation  results  from  bruises,  acrid  discharges  from  the 
vagina,  or  the  extension  of  inflammation  from  that  cavity.  It  is  lo- 
cated about  the  centre  of  the  labium,  and  the  swelling  and  tenderness 
are  great  from  the  beginning.  The  second  form  originates  in  overdis- 
tension of  Duverney's  gland,  from  a  stojDpage  of  its  excretory  duct. 
It  is  situated  deeply  at  the  lower  or  posterior  end  of  the  labium,  and 
'generally  more  slow  in  its  progress.  If  the  patient  is  intelligent,  and 
has  observed  the  case  with  care,  she  will  tell  us  that  there  was  a  little 
ttumor  in  the  seat  of  disease  for  several  days,  sometimes  weeks,  slightl}'' 
^tender  at  first,  but  gradually  becoming  moi'e  so  until  the  abscess  was 
fully  formed.  In  this  stage  the  labium  is  enlarged,  tender,  and  hot, 
but  there  is  not  the  acuteness  of  inflammation  that  is  seen  in  the  first 
variety.  If  the  surgeon  has  an  opportunity  to  examine  the  j^arts 
during  the  progress,  he  will  jDerceive  a  well-defined  tumor,  pyriform  in 
shape,  with  the  small  extremity  directed  to  the  vulva,  while  the  larger 
passes  beneath  the  ramus  of  the  ischium.  It  will  not  seem  to  be,  as  it 
is  not,  in  the  central  part  of  the  labium,  but  beneath  its  under  surface. 
It  will  bear  handling  somewhat  freely,  and  by  pressing  against  the 
iramus,  and  directing  the  pressure  toward  the  vulvar  end  of  it,  the  con- 


PHLEGMON.  145 

tents  may  sometimes  be  pressed  out.  The  contents  in  the  early  stages 
are,  for  the  most  part,  mucus.  If  examined  later,  the  surrounding 
parts,  and  the  labium  particularly,  will  be  found  in  a  state  of  phleg- 
monous inflammation,  which,  in  ten  days  or  two  weeks,  suppurates, 
and  the  pus  is  evacuated  spontaneously.  In  this  form  of  inflammation, 
if  the  duct  of  the  gland  can  be  opened  before  the  inflammation  becomes 
considerable,  suppuration  may  be  avoided.  This  may  be  done  by 
pressing  the  fluid  out,  or  introducing  a  very  small  probe  into  the  canal 
of  the  gland,  thus  opening  it.  If  these  are  both  impracticable,  it  is 
better  to  puncture  it  and  squeeze  the  contents  through  the  outlet  thus 
made.  If  inflammation  has  begun,  we  may  treat  it  like  the  former 
variety,  with  leeches,  purgatives,  evaporating  lotions,  etc.,  in  the  earlier 
period,  and  afterwards  by  poultices  and  anodynes  until  the  suppura- 
tion is  complete,  when  it  should  be  evacuated  by  puncturing  it  on  the 
mucous  surface  of  the  labium.  The  third  variety  is  characterized  by  a 
succession  of  small  furunculi.  They  first  show  themselves  as  small 
points  of  induration  immediately  below  the  mucous  membrane  or 
skin,  are  very  tender,  and  in  the  course  of  a  few  days  suppurate.  One 
scarcely  passes  through  these  stages  before  it  is  succeeded  by  another, 
and  thus  a  continuation  of  them  prolongs  the  march  for  weeks,  and 
even  months,  before  they  cease  to  return.  This  condition  has  existed 
only  in  such  of  my  patients  as  were  the  subjects  of  some  form  of  ute- 
rine disease,  attended  with  leucorrhoea.  They  are  generally  anaemic, 
constipated  and  dyspeptic.  The  radical  treatment  consists  in  curing 
the  disease  of  the  uterus,  correcting  the  state  of  the  bowels  by  mer- 
curial and  saline  cathartics,  and  reinvigorating  the  patient  by  the  ju- 
dicious employment  of  tonics.  We  may  palliate  the  sufferings  of  the 
patient  by  cleanliness,  as  bathing  the  parts  thoroughly  several  times  a 
day  with  pure  cold  water,  and  using  cold-water  injections  per  vaginam, 
and  making  such  application  to  every  hardened  point  as  soon  as  it 
shows  itself  as  will  arrest  its  progress.  I  have  used  successfully  the 
strong  tincture  of  iodine  applied  to  the  part,  and  the  solid  nitrate  of 
silver.  If  either  of  these  applications  is  used  as  soon  as  the  inflamma- 
tion begins,  it  will  sometimes  be  arrested,  and  the  patient  escape  for 
several  days,  or  until  another  furuncle  begins  to  form.  Should  we  be 
unable  to  thus  cut  short  the  inflammation,  we  must  use  poultices  of 
bread  mixed  with  a  solution  of  acetate  of  lead,  and  anodynes,  until 
suppuration  is  perfect.  These  small  points  of  suppuration  usually 
break  themselves,  and  they  will  seldom  be  lanced.  Notwithstanding 
the  fact  that  inflammation  of  the  labia  is  very  painful,  the  patient  will 
in  almost  all  cases  bear  her  distress  until  suppuration  is  complete,  or 
at  least  unavoidable,  so  that  our  treatment  is  generally  confined  to 
that  appropriate  to  the  suppurative  stage.  The  Avhole  process  of 
inflammation  is  rapid,  and  this  may  be  an  additional  reason  why  the 
first  stage  is  not  the  subject  of  observation. 

10 


143       DISEASES    AND    ACCIDENTS    OF    THE    LABIA    AND    PEKINEUM. 

Abscesses  of  the  Labia 

Sometimes  become  chronic,  especially  such  as  find  their  origin  in 
Huguier's  gland.  An  interesting  case  of  this  kind  is  recorded  in  the 
Gynecological  Journal  of  Boston,  second  vol.,  p.  136,  by  Dr.  H.  R. 
Storer: 

"  For  many  years  the  lady  had  found  coitus  almost  impossible,  owing  to  occlusion 
of  vulval  opening  by  lateral  pressure.  She  was  now  sevei'al  months  pregnant,  and  the 
labial  tumor  was  rapidly  increasing.  The  tumor  was  very  irregular  in  outline,  with 
lobulations  and  depressions  such  as  might  easily  have  been  occasioned  by  convolutions 
of  intestine  within  a  thin  hernial  sac.  There  were  present  many  symptoms  of  strangu- 
lated hernia,  and  the  patient's  distress  and  local  suffering  were  extreme.  It  was  im- 
possible, by  the  most  careful  examination,  to  make  a  positive  differential  diagnosis 
though  Dr.  Storer  was  strongly  inclined  to  believe  it  was  a  labial  abscess  of  many 
years'  standing,  taking  its  rise  from  inflammatory  obliteration  of  the  duct  of  Huguier's 
gland.  He  cut  carefully  down  upon  the  most  presenting  portion  of  the  tumor,  and 
obtained  a  free  discharge  of  fetid  pus.  The  sac  was  treated  by  carbolized  tents,  and 
the  patient  made  a  rapid  recovery." 

Labial  abscesses  become  chronic  in  another  waj^ ;  the  duct  of  Hu- 
guier's gland  becomes  obliterated;  an  abscess  and  discharge  of  pus 
take  place  by  spontaneous  eruption ;  the  opening  closes,  and  this  is 
followed  by  reaccumulation,  rupture,  etc.,  and  this  is  repeated  for  an 
indefinite  length  of  time.  This  form  of  chronic  abscess  is  best  treated 
by  laying  the  sac  open  freely  and  emptying  at  once,  or  keeping  it  open 
until  the  contents  are  evacuated,  and  then  every  second  or  third  day 
injecting  a  solution  of  nitrate  of  silver  or  tincture  of  iodine,  or  some 
other  irritant  that  will  awaken  granular  inflammation  in  the  lining 
membrane  of  the  sac.  This  kind  of  treatment  should  be  persevered 
in  until  the  cavity  is  obliterated  completely. 

Labial  Hydrocele. 

A  collection  of  serum  sometimes  found  in  the  labium  of  the  female 
has  received  the  denomination  of  hydrocele,  suggestive  of  its  simi- 
larity to  dropsy  of  the  scrotal  cavity.  The  serous  fluid  occupies  two 
different  positions  in  the  labial  structures.  In  some  persons  the  peri- 
toneum is  protruded  through  the  inguinal  rings  and  down  into  the 
upper  portion  of  the  labium.  In  the  pouch  formed  by  this  descent  of 
the  peritoneal  membrane,  serum  sometimes  collects  in  considerable 
quantity,  and  when  adhesion  at  the  external  ring  takes  place  it  be- 
comes confined.  Thus  an  ovoid  tumor  is  found  with  one  end  at  the 
external  ring,  and  the  other  extending  more  or  less  in  the  upper  part 
of  the  labium.  When  filled  to  great  tension  it  becomes  to  a  consider- 
able extent  translucent  and  very  firm.  I  have  seen  two  of  these  tumors 
decidedly  larger  than  a  hen's  egg.  As  this  protrusion  is  abnormal  the 
tumor  is  very  rare.  Winckel  in  his  new  book  on  gynecology  says  it 
s  oftener  seen  in  the  right  side  and  very  seldom  on  both  sides. 


LABIAL    TUMORS — HYPERTEOPHIEl)    LABIA.  147 

But  another  tumor  receiving  the  same  appellation  is  developed  lower 
down  in  the  labial  structures,  and  occupies  the  imperfect  cavit}^  in  the 
substance  of  the  labium  formed  by  the  prolongations  of  the  two  layers 
of  the  superficial  fascia  of  the  abdomen.  Between  these  layers  is  a 
large  amount  of  loose  cellular  tissue  into  which  serum  may  be  infil- 
trated in  such  quantities  as  to  give  rise  to  quite  a  large  tumor.  This 
tumor  lies  deeper  in  the  substance  of  the  labium  and  is  farther  re- 
moved from  the  external  ring  than  the  others.  It  distends  the  whole 
labium,  enlarging  in  every  direction,  and  sometimes  overrides  the 
labial  fissure  so  as  to  give  the  patient  much  inconvenience. 

The  diagnosis  of  these  collections  is  usually  not  difficult.  They  are 
slow  of  growth,  unaccompanied  by  evidence  of  inflammation,  and  of 
little  importance  in  any  other  respect  than  by  reason  of  their  bulk. 
The  upper  one  is  pronounced,  and,  unhke  hernia,  it  cannot  be  returned 
into  the  abdominal  cavity.  When  the  patient  coughs  it  does  not  re- 
ceive the  abdominal  impulse  as  does  hernia.  The  lower  one  is  distin- 
guished from  the  upper  by  its  more  spherical  shape  and  the  fact  that 
it  does  not  approach  the  inguinal  ring  as  closely  as  the  upper  one. 

They  can  generally  be  promptly  cured  by  incising  them  freely,  in- 
serting a  small  drainage  tube,  and  washing  out  the  cavity  daily. 
Eight  or  ten  days  will  usually  suffice  to  induce  a  granulating  condi- 
tion that  will  destroy  the  secreting  character  of  the  cavity  and  finally 
obliterate  it.  If  the  patient  is  kept  quiet  there  need  be  no  apprehen- 
sion of  unfavorable  conditions. 

Labial  Tumors 

Do  not  differ  in  any  important  respects  from  those  observed  in  other 
parts  of  the  body.  In  structure  they  may  be  fibrous,  fatty,  or  encysted 
fluid.  The  latter  kind  I  have  met  with  more  frequently  than  either 
of  the  others.  The  fibrous  are  next  in  frequency,  and  the  fatty  per- 
haps least.  In  no  respect  does  the  treatment  differ  from  the  treatment 
of  the  same  kind  of  tumors  elsewhere.  They  should  be  dissected  out 
thoroughly,  no  portion  of  tumor  or  cyst  being  left  behind  from  which 
to  be  reproduced.  The  vulvo- vaginal  gland  is  occasionally  developed 
into  a  cystic  tumor  by  the  closure  of  the  duct  through  which  its  con- 
tents are  evacuated.  This  and  the  other  forms  of  encysted  tumors  of 
the  labia  may  be  treated  by  evacuation  and  stimulating  injections 
until  the  sac  is  obliterated. 

Hypertrophied  Labia. 

The  labia  are  sometimes  hypertrophied,  without  much  alteration  of 
structure,  to  such  a  degree  as  to  become  cunibersome  and  troublesome, 
requiring  amputation.  This  may  be  done  by  the  knife  or  ecraseur 
according  to  the  shape  and  size  of  the  superfluous  part. 


148       DISEASES    AND    ACCIDENTS    OF    THE    LABIA   AND    PERINEUM. 


These  organs  are  very  rarely  the  seat  of  elephantiasis,  Fig.  109  (Scan- 
zoni).  They  sometimes  are  enlarged  by  this  disease  to  an  enormous  size, 
extending  down  to  the  knees,  as  shown  in  the  figure  taken  from  Scanzoni. 
If  we  meet  with  this  affection  before  it  has  involved  too  much  of  the 
substance  of  the  parts  to  be  completely  excised,  we  are  justified  in  re- 
moving it ;  but  if  the  skin  on  the  thighs  or  abdomen  is  affected,  so  as 

Fig.  109. 


Elephantiasis  of  the  Labia.— From  Scanzoni's  IXseascs  of  Women. 

to  require  extensive  and  dangerous  dissection,  we  should  not  operate 
for  this  purpose,  but  content  ourselves  by  palliative  treatment,  clean- 
liness, anodyne  lotions,  etc.  It  should  be  remembered  while  consid- 
ering the  propriety  of  removing  small  tumors  of  this  kind  that  they 
very  often  return  and  resist  every  species  of  treatment. 


CAIfCER   OF    THE    LABIA. 


149 


Cancer  of  the  Labia 

Is  not  of  unfrequent  occurrence.  I  have  only  seen  the  epithelial 
variety  in  this  locality.  Two  cases  have  come  under  my  observation 
within  three  years.  The  last  one  was  a  Scotch  woman  fifty-one  years  of 
age.  The  disease  was  located  on  the  left  side.  When  I  first  saw  it  the 
whole  left  labium  (Fig.  110)  presented  an  appearance  so  similar  to 
a  case  illustrated  in  Dr.  McClintock's  work  on  women,  that  I  have 
availed  myself  of  that  figure.  In  my  patient  the  disease  was  on  the 
opposite  side.     When  the  disease  has  not  advanced  so  far  but  that  it 

Fig.  110. 


Cancer  of  the  Labia. — McClintock. 


may  all  be  removed,  we  are  justified  in  excising  it.  We  should  be 
very  particular  to  remove  all  the  morbid  substance.  Scirrhus  probably 
very  rarely  invades  the  labia  majora.  Dr.  McClintock  gives  one  case 
only.  It  does  not  appear  that  other  authors  have  often  met  with  it. 
The  soft  or  fungoid  variety  seems  to  occur  with  even  less  frequency 
than  the  hard  form  of  cancer.  Cancer  of  the  labia  is  attended  with 
similar  symptoms,  and  presents  the  same  appearances  that  it  does  in 
other  organs.  I  need  not  stop  to  give  it  more  attention  in  this  place. 
Absence  of  the  labia  is  very  rarely  observed. 


CHAPTER  VL 

DISEASES  OF  THE  VULVA. 

Condylomata  of  the  Vulva. 

Warty  excrescences  in  great  variety  make  the  vulva  the  seat  of 
their  growth.  They  are  often  flat,  smooth  elevations,  small  usually, 
but  sometimes  as  large  as  filberts,  isolated  or  congregated.  Sometimes 
they  are  sparsely  scattered  over  the  cutaneous  surface  of  the  labia  and 
the  mucous  covering  of  the  vulva,  but  not  unfrequently  they  are 
thickly  crowded  together,  with  deep  fissures  between  them  and  exco- 
riations on  their  surfaces,  that  give  origin  to  acrid  sanious  discharges, 
which  excoriate  the  neighboring  skin  and  soil  the  linen.  The  smell 
from'  this  sanious  discharge  is  sometimes  very  offensive.  These  excres- 
cences are  not  always  smooth  and  rounded  even  when  isolated,  but  oc- 
casionally are  rough  and  ragged,  and  in  a  few  instances  those  spring- 
ing from  the  margin  of  the  vagina  are  arborescent,  slender,  and  from 
half  an  inch  to  an  inch  in  length.  We  again  find  them  yellow,  flat  and 
fragile.  In  most  instances  these  growths  are  confined  to  the  vulva  and 
labia,  but  sometimes  they  cover  a  large  part,  if  not  the  whole  of  the 
mucous  membrane  of  the  vagina  and  cervix  uteri.  I  saw  a  case  quite 
recently  in  which  arborescent  excrescences — many  of  which  were  three- 
fourths  of  an  inch  in  length — sprang  from  the  whole  of  the  vaginal  mu- 
cous membrane.     This  patient  was  pregnant  by  a  syphilitic  husband. 

The  cause  of  these  growths  appears  to  be  the  syphilitic  taint.     So 

far  as  I  now  remember  all  observers  agree  that  syj)hilis  is  the  only 

cause  of  them. 

Treatment. 

We  may  very  properly  trust  the  alterative  course  calculated  to 
remove  the  syphilism  under  which  our  patient  is  laboring  for  the 
relief  of  the  milder  forms  of  these  excrescences,  and  we  should  not 
fail  to  institute  alterative  treatment  for  even  the  more  harassing  vari- 
eties ;  but  in  many  cases  we  will  relieve  the  patient  more  readily  by 
removing  a  part  or  the  whole  of  the  larger  growths  with  scissors,  and 
afterwards  dressing  the  wounded  surfaces  with  mercurial  ointment. 

Inflammations. 

Erythematous,  papular,  vesicular,  and  pustular  inflammations  of  the  vulva 
are  not  unfrequently  observed,  as  are  also  squamous  diseases.  They 
resemble  the  same  form  of  disease  in  other  muco-cutaneous  cavities 
and  the  skin,  and  hence  will  not  here  claim  a  separate  description.    A 


INFLAMMATIONS.  151 

disease  somewhat  more  distinctive,  however,  and  yet  resembling  a  dis- 
ease of  the  mouth,  is  known  as  jjurulent  vulvitis.  This  affection  is 
characterized  by  severe  inflammation  of  the  mucous  membrane  of  the 
vulva,  attended  with  minute  points  of  ulceration,  numbering  from 
one  to  two  dozen.  The  ulcers  are  small,  an  eighth  of  an  inch  in  diame- 
ter, slightly  excavated,  and  almost  always  covered  with  pus.  The 
vulva  is  intensely  red,  and  Bathed  in  pus  and  mucus.  The  inflam- 
mation sometimes  extends  into  the  vagina  and  causes  a  copious  flow 
of  pus  and  mucus  from  that  cavity.  Not  unfrequently  the  labia  are 
very  much  swollen,  and  occasionally  the  deeper  tissues  are  involved 
in  phlegmonous  inflammation.  This  form  of  inflammation  is  not 
unfrequently,  in  its  early  stages,  attended  with  considerable  febrile 
excitement.  To  a  superficial  observer  it  strongly  resembles  gonorrhoea, 
from  the  swollen  labia,  burning  pain,  copious  muco-purulent  discharge, 
and  the  difficult  and  painful  micturition.  Its  occasional  sudden  and 
unexpected  development  adds  to  this  similitude,  and  legal  proceed- 
ings have  been  instituted  against  parties  supposed  to  have  been  in- 
strumental in  imparting  the  disease  to  little  girls.  It  occurs  in  children 
generally  from  two  to  ten  or  twelve  years  of  age,  and  probably  results 
from  want  of  cleanliness,  heat,  and  local  irritants  accidentally  aj)plied. 
If  allowed  to  pursue  its  course  undisturbed  by  treatment,  other  than 
cleanliness,  it  will  generally  subside  spontaneously  in  two  or  three 
weeks,  or  in  the  course  of  that  time  become  very  much  subdued,  and 
run  into  chronic  inflammation  without  ulceration.  This  last  is  often 
extended  into  adolescence,  and,  as  vaginitis,  gives  origin  to  the  leucor- 
rhoea  of  girlhood,  and  finally  to  the  endometritis  of  the  woman.  It 
sometimes  attends  upon  a  debilitated  and  scrofulous  constitution,  and 
is  complicated  with  indigestion,  constipation,  and  ascarides ;  but  it  is 
hot  likely  originated,  though  aggravated  and  fostered,  by  these  atten- 
dant circumstances. 

Treatment. 

The  treatment  is  general  and  local.  In  the  beginning,  where  the 
inflammation  is  high,  it  should  be  antiphlogistic  and  soothing.  We 
ma}^  administer  a  mercurial  cathartic,  and  quicken  its  action  by  a 
saline  laxative,  and  after  the  bowels  have  been  thoroughly  moved, 
nitrate  of  potassa  may  be  given  internally,  every  three  or  four  hours, 
in  doses  to  suit  the  age  of  the  joatient.  The  parts  should  be  frequently 
bathed  or  fomented  with  a  decoction  of  poppy-heads,  or  with  the 
watery  extract  of  opium.  In  the  course  of  four  or  five  days  the  acute 
symptoms  will  begin  to  subside,  when,  in  addition  to  attention  to  the 
bowels,  we  may  administer  an  acid  solution  of  quinine  internally,  and 
begin  the  use  of  astringents  locally.  A  solution  of  tannin,  sulphate 
of  zinc,  acetate  of  lead,  or  other  astringent,  Aveak  at  first,  and  after- 
wards increased  in  strength,  may  be  applied  freely  to  the  parts  four  or 


152  DISEASES    OF    THE    VULVA. 

five  times  a  clay.  These  remedies  will  generally  remove  the  inflam- 
mation in  a  reasonable  time.  The  astringent  should  be  increased  in 
strength  to  a  sufficient  degree  for  the  purpose.  If  those  mentioned 
are  not  strong  enough,  the  chloride  of  zinc,  sulphate  of  copper,  or 
even  nitrate  of  silver,  may  be  very  properly  resorted  to.  Should  the 
inflammation  extend  into  the  vagina,  the  astringent  may  be  injected  into 
that  cavity  by  means  of  a  small  hard-rubber  syringe.  We  ought  to 
be  careful  to  use  a  very  small  syringe,  and  not  to  introduce  it  too  far. 
The  nurse  should  be  carefully  instructed  in  this  kind  of  application, 
I  feel  impelled  to  insist  upon  the  complete  removal  of  the  inflamma- 
tion as  early  as  it  can  reasonably  be  done,  believing  that  if  it  continues 
until  puberty,  the  inflammation  extends  into  the  body  of  the  develop- 
ing uterus,  and  entails  a  very  distressing  train  of  suffering  upon  the 
patient,  that  might  have  been  avoided  by  an  early  and  complete  cure 
of  the  vaginitis.  I  am  persuaded  that  too  much  importance  cannot 
be  attached  to  these  views. 

Follicular  Vulvitis. 

Inflammation  of  the  vulva,  instead  of  affecting  the  mucous  mem- 
brane, as  in  the  purulent  form,  is  sometimes  confined  to  the  follicles 
and  glands  of  the  vulva.  In  this  form  of  the  disease  minute  papil- 
lary elevations  on  the  mucous  surface  of  the  labia  majora,  the  nym- 
phse,  the  prepuce  of  the  clitoris,  and  elsewhere  in  the  orifice  of  the 
vagina  are  first  observed.  These  increase  in  size  and  become  red, 
while  the  intervening  mucous  membrane  is  often  very  much  inflamed. 
In  many  instances  a  number  of  these  elevations  become  pustules, 
their  bases  hardened,  red,  and  very  tender.  Oftener  there  is  only  a 
copious  flow  of  mucus  stained  with  pus-corpuscles  from  the  follicles. 
The  acute  form  will  generally  run  its  course  and  subside  in  a  few 
weeks,  sometimes  in  from  ten  to  twenty  days.  But  follicular  vulvitis 
occasionally  becomes  chronic,  and  then  is  exceedingly  obstinate  and 
difficult  of  cure. 

Causes. 

Want  of  cleanliness,  vaginitis,  pregnancy,  and  malignant  afFections 
of  the  vagina  and  uterus  are  the  most  frequent  causes. 

Tj'eatment. 

The  treatment  should  be  rest  in  the  recumbent  posture,  alterative  and 
saline  cathartics,  cleanliness,  first  emollient  poultices,  and  afterwards 
astringent  washes  and  applications.  If  the  patient  be  debilitated,  the 
bitter  tonics,  quinine  especially,  will  be  found  useful.  The  subjects 
of  this  form  of  vulvitis  generally  require  supporting  and  tonic  treat- 
ment. When  the  secretions  are  offensive,  carbolized  glycerin  should 
be  freely  applied,  two  or  three  times  a  day. 


PRURITUS    PUDENDI.  .  153 

When  it  is  chronic,  tliere  will  be  necessity  for  the  use  of  stimulants 
so  strong  as  to  modify  the  inflammation.  Nitrate  of  silver  in  substance 
applied  once  in  seven  or  eight  days  to  the  whole  of  the  inflamed  sur- 
face will  sometimes  cause  the  disease  to  yield.  In  connection  with 
this  glycerin,  with  tannic  acid  dissolved  in  it,  or  impregnated  with 
creasote,  may  be  used  between  the  applications. 

Alteratives  are  often  found  to  be  very  beneficial.  Iodide  of  potas- 
sium, sarsaparilla,  stillingia,  and,  in  plethoric  patients,  mercury  are 
the  ones  on  which  most  reliance  may  be  placed. 

Dr.  Thomas  speaks  of  having  made  a  cure  by  ''  dissecting  off  the 
whole  mucous  membrane  lining  the  vulva." 

Pruritus  Pudendi. 

A  very  annoying  and  often  obstinate  affection  of  the  genital  organs 
is  an  inordinate  itching  of  the  vulva.  The  itching  returns  in  paroxysms. 
The  patient  may  be  free  from  it  except  when  standing  by  a  warm  fire, 
or  when  heated  by  exercise,  passion,  etc.  Or  she  may  be  affected 
only  at  or  near  the  menstrual  period.  Again,  the  paroxysms  return 
without  any  apparent  cause.  In  one  variety  of  the  disease  the  sensa- 
tion sometimes  is  that  of  a  burning  glow,  attended  with  an  irresistible 
desire  to  rub  or  scratch  the  parts,  a  desire  which  the  most  delicate 
sense  of  propriety  cannot  always  keep  within  due  bounds.  In  another 
the  sensation  is  such  as  might  be  produced  by  the  crawling  of  pediculi, 
and  the  patient  is  sure  that  thousands  of  these  insects  are  moving 
upon  her  person,  and  will  be  convinced  to  the  contrary  only  by  in- 
spection. This  feeling  of  formication,  although  very  disagreeable,  is 
a  slight  inconvenience  compared  to  the  sufferings  of  the  other  variety. 

The  former  variety  is  almost  always  attended  with  inflammation  of 
the  mucous  membrane  of  the  vulva.  The  accompanying  inflammation 
may  be  simply  erythematous,  papular,  or  vesicular.  Dr.  Dewees 
describes  a  variety  of  vesicular  inflammation  resembling  aphtha, 
attended  with  pruritus.  I  am  sure  that  neither  the  papulae  nor  vesiculse 
are  always  present  in  very  distressing  cases,  although  I  have  not  seen 
this  affection  when  the  parts  were  not  in  some  way  inflamed.  It  may 
be  observed  that,  in  the  formication  variety  of  pruritus,  the  itching  is 
generally  in  great  part  if  not  wholly  confined  to  the  cutaneous  surface 
of  the  labia.  It  will  be  inferred  that  I  consider  pruritus  but  a  symptom 
of  several  diseased  conditions,  generally  of  the  genital  organs  but 
sometimes  undoubtedly  caused  by  irritation  in  the  intestinal  tube, 
particularly  the  rectum,  or  by  some  other  remote  cause.  An  intelligent 
scrutiny  of  the  cases  as  they  arise  will  most  frequently  result  in  the 
discovery  of  the  originating  condition.  It  is  often  an  obstinate  affec- 
tion, lasting  in  bad  cases  for  weeks,  months,  and  even  years,  but  more 
frequently  it  is  amenable  to  a  judicious  course  of  treatment. 


154  DISEASES    OF    THE   VULVA. 

Treatment. 

The  first  thing  to  be  done  is  to  remove  the  cause,  when  practicable. 
In  order  to  do  this,  the  abdominal  organs  will  require  attention. 
The  sluggish  secretions  and  bowels  must  be  corrected  by  alteratives 
and  laxatives.  A  mercurial,  say  five  grains  of  blue  pill,  may  be  given 
at  night,  to  be  followed  in  the  morning  by  a  saline  laxative,  sufficient 
to  cause  one  or  two  stools.  This  may  be  repeated  at  intervals  of  from 
one  to  four  days,  until  the  object  is  gained.  Meantime,  if  the  stonipch 
is  weak  and  digestion  imperfect,  the  bitter  infusions,  with  alkalies  or 
acids,  as  the  condition  may  require,  will  be  demanded ;  and  should 
the  patient  be  anaemic,  iron  may  be  given.  Sometimes  the  patient 
will  be  plethoric,  when  the  alteratives,  with  spare  diet,  will  do  better. 
With  the  above  treatment,  if  the  health  be  faulty,  or  without,  if  this  is 
not  the  case,  we  will  generally  be  obliged  to  resort  to  local  remedies. 
And  first  of  all  is  cleanliness.  The  parts,  externally  and  internally, 
must  be  subjected  to  thorough  and  frequently  repeated  ablutions. 
The  sj^ringe  may  and  should  be  brought  into  use  for  this  purpose 
from  three  to  a  dozen  times  a  day.  The  water  used  for  ablutions  may 
be  impregnated  with  sal  soda  very  appropriately,  or  some  fine  toilet 
soap.  I  have  found  much  advantage,  when  there  was  no  eruptive 
accompaniment,  from  two  drachms  of  the  tincture  of  the  chloride  of 
iron  in  a  quart  of  water,  three  or  four  times  a  day.  This  is  especially 
useful  when  there  is  leucorrhoea,  and  a  congested,  dark  ai^pearance  of 
the  mucous  membrane.  When  there  is  a  vesicular  eruption,  the 
recommendation  of  Dr.  Dewees,  to  sj)rinkle  the  parts  with  powdered 
borax,  and  keep,  them  exposed  as  much  as  possible  to  the  air,  will  be 
of  great  service.  Professor  Simpson  uses  chloroform,  in  the  forms  of 
vapor,  liniment,  or  ointment,  with  good  effect.  TJie  infusion  of  tobacco, 
applied  freely,  two  or  three  times  a  day,  is  recommended  by  the  same 
author.  Simple  cerate,  or  oxide  of  zinc  ointment  containing  5  to  10 
per  cent,  of  carbolic  acid  is  a  good  palliative.  When  the  mucous 
membrane  is  much  inflamed,  a  solution  of  hydrocyanic  acid,  ten  drops 
to  the  ounce  of  water,  often  gives  great  relief.  A  strong  solution  of 
tannin  and  aqueous,  extract  of  opium  is  also  applicable  to  this  class  of 
cases.  An  excellent  palliative  is  pure  glycerin.  It  may  be  introduced 
into  the  vagina  b}'  saturating  a  plug  of  cotton,  passing  it  up  through  a 
glass  speculum  and  allowing  it  to  remain  there  for  ten  or  twelve  hours. 
We  should  take  the  precaution  to  attach  a  thread  or  cord  to  the  cotton 
so  that  it  may  be  readily  removed.  One  of  them  introduced  every 
twelve  or  twenty-four  hours  is.  often  enough.  We  should  also  apply 
it  between  the  labia  in  the  same  way.  As  explained  by  Dr.  Sims,  who 
first  recommended  its  use,  the  glycerin  induces  copious  serous  deple- 
tion from  the  congested  mucous-  membrane,  thus  relieving  it. 

In  cases  of  some  duration  I  have  often  been  enabled  to  produce  a 


CORRODING  ULCER.  155 

decidedly  favorable  change  by  applying  the  tincture  of  the  chloride  of 
iron  in  full  strength  with  a  brush  once  a  day  to  all  the  mucous  mem- 
brane of  the  vulva,  and. as  far  in  the  ostium  vaginae  as  I  could  pass 
the  hair-pencil.  The  first  burning  sensation  is  succeeded  by  great 
amelioration  of  the  sufferings,  and  finally,  in  many  cases,  by  a  cure. 
When  this  fails,  we  may  sometimes  succeed  by  making  a  similar 
application  of  a  solution  of  nitrate  of  silver  in  the  strength  of  3ss  to  §j 
of  water.  This  last  ajjplication  should  not  be  used  oftener  than  once 
in  two  days.  In  the  use  of  all  these  remedies  we  must  not  lose  sight 
of  the  ablutions,  nor  fail  to  search  for  particular  local  causes,  and  try 
to  remove  them.  As  has  been  very  judiciously  remarked  by  Professor 
Simpson,  we  will  find  great  advantage  in  alternating  the  use  of  appro- 
priate remedies,  instead  of  using  the  same  kind  all  the  time.  The 
obstinacy  of  this  affection  will  require  great  patience  in  many  instances, 
as  well  as  ingenuity  in  using  remedies. 

Corroding  Ulcer. 

I  have  met  with  a  number  of  cases  of  corroding  ulcer  of  the  vulva 
in  children,  which  have  been  the  cause  of  great  suffering  and  appre- 
hension. It  occurs  most  frequently  in  children,  but  is  occasionally 
met  with  in  adults.  There  is  in  each  case  usually  but  one  ulcer,  and 
it  is  most  commonly  situated  on  the  lesser  labia  at  first,  and  spreads 
to  surrounding  j^arts.  The  ulcer  is  ragged  and  irregular,  not  much 
excavated,  with  a  dark  foul-smelling  covering,  and  the  discharge  from 
it  is  sanious,  fetid,  and  excoriating.  It  is  not  generally  rapid  in  its 
progress,  and  sometimes  lasts  for  months,  creeping  from  one  part  tO' 
another  until  the  anatomical  features  of  the  vulva  are  almost  entirely 
effaced.  I  have  not  met  with  this  form  of  disease  except  in  very 
debilitated,  sallow,  and  badly  nourished  persons.  The  state  of  the 
system  leading  to  this  sort  of  ulceration  I  have  thought  to  be  more- 
particularly  the  result  of  living  in  poorly  ventilated  houses,  but  coupled 
also  with  imj)erfect  nourishment,  or  with  nourishment  of  an.  improper 
character. 

It  is  generally  obstinate,  and  yields  but  slowly  to  judicious  treat- 
ment. 

We  should  endeavor,  as  one  of  the  main  objects,  to  correct  the  con- 
stitutional condition  as  speedily  as  possible.  To  this  end  the  circum- 
stances of  the  patient  should  be  changed  to  the  most  favorable  sort. 
Good  ventilation  at  home,  frequent  and  prolonged  exposure  to  the 
fresh  air,  nourishing  diet,  of  which  animal  food  should  be  a  large 
ingredient,  and  comfortable  clothing,  with  thorough  cleanliness,  are 
indispensable  to  success.  The  bowels  should  be  kept  in  as  correct  a 
condition  as  possible  by  gentle  laxatives.  The  digestion,  Avhich  is 
alwaj^s  feeble,  if  not  otherwise  faulty,  may  be  improved  by  the  admin- 


]56  DISEASES   OF   THE   VCLVA. 

istration  of  infusion  of  cinchona,  quassia,  or  colomba,  with  the  mineral 
acids,  the  sulphuric  being  perhaps  the  best.  The  chlorinated  tincture 
of  iron  is  also  an  excellent  general  remedy.,  The  next  thing  to  be 
accomplished  is  to  convert  the  ataxic,  half-sloughing,  and  corroding 
chronic  ulcer  into  an  acute  inflammatory  one.  This  is  done  by  pro- 
foundly stimulating  it  with  the  stronger  caustics.  The  one  which  has 
seemed  to  me  to  be  most  successful  is  the  caustic  potassa.  It  should 
be  applied  to  the  whole  surface  by  passing  a  stick,  not  very  rapidly, 
all  over  it.  After  this  burning  we  may  dress  the  ulcer  with  calamine 
ointment  twice  a  day.  This  will  almost  immediately  improve  the 
condition  of  the  sore.  Unless  there  is  some  considerable  firmness 
around  and  beneath  it,  caused  by  the  effusion  of  fibrin  in  the  submu- 
cous substance  in  thirty-six  or  fortj^-eight  hours  after  the  application 
of  the  caustic  potassa,  not  much  good  will  result  from  it,  and  it  will  be 
necessary  to  resort  to  it  or  some  other  in  a  few  days.  The  strong 
nitric  acid  is  also  very  useful.  I  have  not  tried  the  actual  cautery, 
but  should  expect  it  to  be  very  useful.  We  may  often  cure  this  ulct)r 
by  the  weekly  application  of  the  solid  nitrate  of  silver,  dressing  it 
between  times  with  lint  saturated  with  black  wash,  calamine  ointment, 
or  with  iodoform  gauze.  We  ought  not  to  be  afraid  of  strong  treat- 
ment, nor  to  continue  it  in  conjunction  with  a  highly  roborant  general 
course  of  exercise  and  diet. 

Gangrenous  Vulvitis,  or  Noma. 

This  is  a  very  severe  and  generally  fatal  affection  of  the  genital 
organs,  occurring  usually,  if  not  wholly,  among  children.  It  may 
attack  one  or  both  sides  simultaneously.  In  the  few  cases  I  have 
seen  there  appeared  a  bleb  or  blister  on  the  inside  of  the  mucous  sur- 
face of  the  labium,  which  at  the  same  time  became  enlarged,  hard, 
tender,  and  painful.  In  a  few  hours  the  blister  breaks,  and  from  its 
side  a  not  very  abundant  but  acrid  serum  is  discharged.  At  this 
time  a  peculiar  odor  is  emitted  from  the  parts.  All  around  the  ash- 
colored  surface,  which  represents  the  place  where  the  blister  was  de- 
veloped, the  substance  of  the  labium  is  very  hard  and  much  swollen. 
In  two  or  four  days  the  affected  side  is  in  a  state  of  gangrene,  the 
discharge  is  very  much  increased,  the  parts  upon  which  it  runs  are 
excoriated  and  inflamed,  and  an  intolerable  stench  is  exhaled.  I 
have  not  seen  an  instance  in  which  the  gangrenous  parts  were  cast 
off,  the  patients  having  died  beforehand.  Generally,  though  not 
always,  in  the  very  beginning,  the  circulation  and  nervous  system 
are  very  much  disturbed.  The  pulse  is  quick  and  feeble,  the  patient 
nervously  restless,  or  else  stupid,  the  extremities  cool,  the  body — 
particularly  about  the  pelvis — hot,  the  tongue  furred,  generally  brown, 
and  the  skin  dingy  and  sallow.     As  the  disease  advances  the  pulse 


URETHRAL    EXCRESCENCES.  157 

becomes  still  more  rapid  and  weak,  the  extremities  cold,  the  mind 
wandering,  and  the  restlessness  amounts  to  the  frantic  efforts  of  some 
sort  of  delusion.  The  tongue  becomes  dark  brown  or  black,  the  teeth 
are  covered  with  sordes,  and  in  the  end  the  patient  often  sinks  into 
profound  coma,  and  dies. 

The  disease  runs  its  course  sometimes  in  forty-eight  hours,  and 
again,  in  milder  forms,  it  may  last  five  or  six  days.  The  causes, 
although  unknown,  must  undoubtedly  be  of  a  depressing  nature, 
overwhelming  the  organism  very  rapidly.  It  occurs  sporadically, 
when  it  is  comparatively  mild,  and  epidemically  when  severe.  In 
this  last  state  it  is  very  rapidly  fatal. 

The  prognosis  is  very  bad,  as  it  is  always,  or  pretty  nearly  always, 
fatal.  The  profession,  so  far  as  I  am  aware,  has  not  decided  whether 
the  disease  is  a  general  one,  and  the  affection  of  the  genital  organs  an 
incident,  or  whether  the  local  disease  inaugurates  the  general  symp- 
toms. The  former  is  most  likely  the  truthful  interpretation  of  the 
phenomena. 

In  such  a  disease  there  is  little  prospect  of  a  cure  by  treatment ;  we 
should,  nevertheless,  institute  a  course  clearly  indicated  by  the  symp- 
toms and  signs.  The  general  treatment  should  be  strongly  stimulant, 
tonic,  and  supporting ;  quinia,  brandy,  tincture  of  cantharides,  and 
beef  essence,  as  much  as  the  patient  can  bear,  should  be  administered. 
I  do  not  think  the  strong  caustic  local  treatment,  generally  advised, 
any  better,  if  as  good,  as  the  charcoal  and  yeast  poultices,  chloride  of 
lime,  anodyne  fomentations,  and  cleanliness.  Much  attention  should 
be  devoted  to  thorough  ventilation,  isolation  of  the  patient,  and  the 
neutralization  of  the  fetor  by  disinfectants. 

Urethral  Excrescences. 

Caruncles  of  the  urethra;  vascular  tumor  at  the  orifice  of  the 
urethra:  These  names  have  been  given  to  small  tumors  springing 
from  the  mucous  membrane  of  the  vulva,  immediately  around  the 
urethral  orifice,  or  from  the  lining  of  the  urethra  itself.  They  are 
generally  solitary,  but  sometimes  there  are  several.  Sometimes  they 
are  sessile,  and  seem  to  be  a  hypertrophied  fold  of  the  mucous  mem- 
brane of  the  orifice  ;  at  others  they  are  polypoid  in  their  attachment. 
In  size  they  vary  from  a  pin's  head  to  a  small  nut.  They  also  vary 
in  their  appearance.  As  before  remarked,  they  sometimes  resemble 
in  color,  consistence,  and  polish  the  mucous  membrane  upon  which 
they  are  planted ;  while  in  other  cases  they  are  quite  red,  almost 
scarlet,  very  soft,  and  easily  broken.  They  differ  in  their  anatomical 
properties  quite  as  much  as  in  appearance,  seeming  in  some  instances 
to  have  no  more  vessels  and  nerves  than  other  portions  of  the  neigh- 
boring tissue,  while  in  others  they  are  formed  mostly  of  capillary 


158  DISEASES    OF    THE    VULVA. 

bloodvessels  and  loops  of  nerves.  They  are  a  morbid  develojDment 
of  existing  tissues  instead  of  a  growth  of  abnormal  substance.  These 
tumors  are  often  observed,  particularly  the  more  dense  and  light- 
colored  varieties,  without  giving  origin  to  any  symptom  that  would 
lead  to  their  detection  ;  on  the  other  hand,  in  many  instances,  they 
often  produce  the  most  excruciating  suffering.  The  kind  of  caruncle 
that  has  seemed  to  me  to  be  the  important  one  is  the  blood-red  tumor 
projecting  from  the  mouth  of  the  urethra  and  attached  by  a  small 
neck.  A  few  weeks  since  I  met  with  one  of  these  of  crescentic  shape, 
attached  by  a  neck  that  arose  from  the  concave  margin,  and  had  its 
other  attachment  inside  the  urethral  orifice.  It  would  not  have 
weighed  two  grains,  but  it  caused  agonizing  symptoms.  It  must  not 
be  supposed  that  all  of  the  varieties  will  not  occasionally  cause  great 
13ain.  The  symptoms  of  their  presence  are  almost  always  connected 
with  the  evacuation  of  the  bladder  and  attempts  to  handle  the  part. 
The  passage  of  urine  causes  the  most  excruciating  suffering  from  pain 
and  tenesmus,  the  patient  often  straining  for  several  minutes  after  the 
complete  discharge  of  the  urine.  The  slightest  touch,  also,  is  the 
cause  of  great  pain.  The  diagnosis  cannot  be  clear  without  an  ocular 
examination.  If  the  parts  are  exposed  to  a  good  strong  light,  and 
the  labia  separated,  the  excrescence  will  be  at  once  discovered,  unless 
it  be  quite  inside  the  urethra.  If  any  doubt  exists,  we  should  intro- 
duce the  finger  into  the  vagina,  and  press  the  urethra  forward.  It  is 
difficult  to  say,  with  truthfulness,  what  are  the  causes  of  these  carun- 
cul£e.  My  cases  have  been  in  patients  ob^dously  deficient  in  cleanli- 
ness. This  seems  to  have  been  the  cause  in  that  which  came  under 
Dr.  "West's  observation. 

The  treatment  is  simple,  and  consists  in  two  main  objects  :  1st,  the 
thorough  removal  of  them ;  and  2d,  the  production  of  a  profound 
imjDression  upon  the  point  of  origin.  In  fact,  the  tissues  from  which 
they  spring  should  be  destroyed  to  a  slight  depth.  The  first  object 
may  be  most  readily  gained  by  snipping  off  deeply  with  scissors ;  and 
the  second  by  holding  nitric  acid,  or  applying  the  actual  cauter}-,  to 
the  place  until  the  nidus  is  destro3'ed. 

Vascular  Urethra. 

Analogous  to  the  caruncle  is  the  vascular  urethra.  It  gives  rise  to 
the  same  train  of  symptoms,  though  not  so  intensely  distressing,  and 
is  very  persistent.  It  occurs  more  frequently  in  patients  near  the 
climacteric  period,  although  I  have  seen  it  in  much  j^ounger  persons. 
When  the  labia  are  se^Darated,  and  the  parts  exposed  to  a  good  light, 
the  urethra  is  seen  to  be  patent,  and  the  tissues  around  the  orifice 
swollen  and  of  deeper  hue  than  usual.  The  mucous  membrane  of  the 
urethra  is  of  an  intensely  scarlet  color,  and,  upon  minute  inspection, 


HYPERTROPHY    OF    THE    CLITORIS    AND    NYMPHA.  159 

the  vessels  may  be  seen  enlarged ;  it  is  very  tender  and  sensitive  to 
the  touch,  slight  contact  producing  exquisite  pain.  There  is  great 
burning  and  sense  of  cutting  when  urine  is  voided,  and  all  the  symp- 
toms, even  the  sympathetic  nervous  derangements,  attendant  upon 
caruncle.  This  condition  is  not  incipient  caruncle,  for  there  is  no 
elevation,  no  protrusion,  and  the  condition  lasts  for  years  without 
material  change  of  substance.  The  treatment  I  have  found  most 
effective  is  dilatation  and  the  use  of  strong  nitric  acid,  applied  cau- 
tiously to  the  membrane  inside  the  urethra.  The  passage  of  a  large 
urethral  sound  twice  a  week  sometimes  exerts  a  beneficial  alterative 
influence. 

Hypertrophy  of  the  Clitoris  and  Nympha. 

It  is  very  rare  that  we  meet  with  hypertrophy  of  these  organs 
without  morbid  change  in  the  tissues.  There  is  either  cystic  devel- 
opment in  their  substance  or  degeneration  of  the  membranous  tissues. 
The  two  diseases  that  seem  to  contribute  most  frequently  to  this  en- 
largement are  syphilis  and  eleiDhantiasis. 

Treatment. 
Removal  by  the  thermocautery. 


CHAPTER    VII. 

LACERATION  OF  THE  PERINEUM  AND  PELVIC  FLOOR. 

The  structure  of  the  perineum  and  pelvic  floor,  and  their  relation 
to  each  other  and  to  the  uterus,  have  been  briefly  considered  in  the 
first  and  third  chapters.  A  few  preliminary  observations  about  their 
relation  to  labor  will  also  be  necessary  to  prepare  the  way  for  a  dis- 
cussion of  the  treatment  of  injuries  of  these  parts. 

Preliminary  Observations  upon  the  Conditions  leading  to  Injuries  of 
the  Parturient  Canal. 

At  the  beginning  of  normal  labor  the  occiput  projects  into  the  pelvic 
cavity  below  the  level  of  the  pubic  arch.  As  the  external  os  uteri  di- 
lates and  is  drawn  up  over  the  head,  elevating  with  it  the  pubo-uterine, 
sacro-uterine  and  broad  ligaments,  the  bag  of  waters  presses  down 
against  the  pelvic  floor,  dilates  the  vagina,  fills  the  pelvis,  and  in  some 
cases  protrudes  at  the  vulval  orifice.  The  fetal  head,  following  the 
bag,  dilates  the  more  rigid  parts,  and  is  directed  by  the  conformation 
of  the  pelvic  cavity  over  the  folded  and  retracted  perineal  raphe  into 
the  dilating  vaginal  and  vulval  orifices. 

One  of  the  most  frequent  deviations  from  this  method  is  a  prema- 
ture rupture  of  the  membranes.  In  a  much  larger  percentage  than 
has  -been  supposed  they  rupture  at  or  before  the  beginning  of  labor,* 
and  allow  the  amniotic  fluid  to  drain  off.  As  soon  as  it  has  escaped 
active  labor  pains  come  on,  drawing  the  cervix  rapidly  over  the  head, 
and  often  producing  a  laceration  of  the  cervix  that  may  extend  into 
the  vagina,  and  thus  inaugurate  a  series  of  lesions.  Having  neither 
its  normal  protection,  the  pouch  of  membranes,  nor  an  oozing  amniotic 
fluid  to  lubricate  it,  the  vagina  is  dragged  down  toward  the  vulva,  and, 
if  the  upper  part  be  thus  lacerated  or  the  head  be  proportionately  too 
large,  may  be  torn  loose  from  the  receding  uterine  ligaments  and  their 
surrounding  connective  tissue.  As  the  head  descends  the  mucous  mem- 
brane may  be  loosened  from  its  intimate  fascial  connection  with  the 
levator  vaginse  and  pubic  arch,  and  perhaps  torn  asunder  along  with 
the  weaker  perineal  tissues.     The  rectum  may  also  be  dragged  loose 

*  According  to  G.  W.  H.  Kemper  (Am.  Jonrn.  Med.  Science,  April,  1885,  p.  412) 
and  J.  C.  Bliss  they  occur  in  from  seven  to  ten  per  cent,  before  the  onset  of  labor.  In 
iny  private  obstetrical  practice,  which  is  mostly  among  delicate  or  sickly  primipara, 
and  multipara  who  have  uterine  disease,  the  percentage  of  such  premature  ruptures 
has  been  during  the  past  year  as  high  as  forty  per  cent. 


THE    SCIATIC    AND    COCCYGEAL   SURFACE.  161 

from  its  naturally  firm  and  unyielding  sacral  attachments,  behind  and 
below  the  sacro-uterine  ligaments.  If  the  membranes  rupture  later,  at 
any  time  before  reaching  the  vulva,  a  similar  unfavorable  change  occurs 
in  labor,  but  it  involves  chiefly  the  ijarts  lower  down.  Other  things 
being  equal,  the  greater  the  amount  of  perineal  dilatation  at  the  time 
of  the  rupture  of  the  membranes,  the  more  will  any  injuries  that  may 
occur  be  confined  to  the  lower  and  superficial  structures. 

When  the  head  remains  at  the  pelvic  brim  during  the  first  stage  of 
labor,  the  upward  traction  upon  the  cervix,  vaginal  fornices,  and  con- 
tiguous structures  separates  and  attenuates  them,  and  deprives  both 
the  cervix  and  vagina  of  their  connective-tissue  support.  This  length- 
ening of  the  parturient  tube  from  the  internal  os  down  diminishes  also 
its  transverse  distensibility  and  predisposes  to  laceration. 

Expulsive  efforts  during  the  first  stage  are  very  commonly  employed 
by  multipara,  and  occasionally  by  misdirected  primipara.  This  forces 
the  foetus  down  before  the  maternal  parts  have  had  time  to  retract,  and 
unduly  hastens  dilatation  while  interfering  with  retraction. 

A  rapid  instrumental  delivery,  by  affording  too  little  time  for 
moulding  of  the  head  and  the  dilatation  and  adjustment  of  the  ma- 
ternal tissues,  must  lead  to  a  laceration  in  all  but  the  previously 
lacerated  or  abnormally  relaxed  outlet.  The  greater  number  of  forceps 
are  so  constructed  that  one  or  both  blades  press  or  cut  into  the  vaginal 
levator  vaginse  and  constrictor  cunni  of  one  or  both  sides  and,  by  the 
irritation  they  produce,  tend  to  bring  on  disastrous  expulsive  efforts. 

Imperfect  development  of  the  pelvis,  vagina  and  perineum,  pelvic 
deformity,  cicatrices,  rigidity  from  age,  fetal  abnormalities,  etc.,  consti- 
tute conditions  that  must  also  be  understood  by  the  gynecologist,  and 
which  should  be  carefully  studied  in  treatises  on  obstetrics. 

The  Mechanism  of  Laceration  and  Injuries  of  the  Perineum  and 
Pelvic  Floor. 

Whether  it  be  admitted  or  not  that  the  bag  of  waters  can  as  a  rule 
be  preserved  to  dilate  the  vaginal  and  vulval  outlets,*  a  reference  to 
Figs.  Ill  and  112  will  show  the  advantage  the  perineum  gained  by 
such  preservation. 

The  Sciatic  and  Coccygeal  Surface. 

The  curved  lines  (Fig.  Ill),  marked  to  represent  the  anterior  edges 
of  the  smaller  sacro-sciatic  ligament  and  coccygeus  muscle,  run  from 

*  In  nine-tentlis  of  my  private  obstetric  cases  during  the  past  year  in  which  the 
membranes  remained  intact  until  complete  dilatation  of  the  external  os  uteri,  they 
protruded  from  the  vulva  before  rupturing.  In  one-third  of  these  cases  the  head  was 
born  with  the  membranes  intact. 

11 


162 


LACERATIOX   OF   THE    PERINEUM    AND    PELVIC    FLOOR. 


the  ischial  spines  to  the  coccyx.  They  may  be  felt,  at  the  beginning 
or  subsidence  of  a  pain,  as  the  anterior  edge  of  the  flat  surfaces  upon 
which  the  frontal  region  rests  while  the  perineum  is  being  dilated. 
It  will  be  noticed  that  the  vulval  orifice  is  larger  in  Fig.  Ill  than  in 
Fig.  112,  while  the  frontal  region  is  still  comj^letely  supported  upon 

Fig.  111. 


Folding  of  the  Perineal  Body  in  Normal  Labor  when  Dilated  by  means  of  the  Bag  of  Waters  or 

Caput  Suecedaneum  (%). 
The  dots  on  the  perineal  body  indicate  connective  tissue  containing  fat. 
p.  c,  post,  commissure ;  e.  c.  c,.,  edge  constrictor  cunni  or  vulval  sphincter  ;  e.  I.  v.,  edge  levator 
vaginse  or  vaginal  sphincter;  a.,  anus;  e.l.a.,  edge  levator  ani;  e.l.c,  edge  levator  coccygei; 
e.  c,  edge  coccygeus  ;  s.  s.  I.,  smaller  sacro-sciatic  ligament. 

these  planes.  This  part  of  the  pelvic  floor  is  dilated  but  little,  and  is 
seldom  injured  except  by  contusion.  Schatz  diagnosticated  one  lacera- 
tion extending  by  the  side  of  the  coccyx.* 

Plane  of  Obturato-Coccygeus. 
From  this  plane  to  the  curve  marked  in  the  figure  as  the  edge  of  the 
levator  coccygei,  and  which  can  often  be  traced  as  a  ring  around  the 
head  extending  from  the  pubic  bone  on  either  side  to  the  tip  of  the 

*  Archiv  fiir  Gynecologie,  vol.  xxii.,  p.  302. 


THE   LEVATOR   COCCYGET. 


1G3 


coccyx,  lies  the  posterior  section  of  the  levator  ani,  or  ohturato- 
coccygeus.  It  is  less  rigid,  and  has  only  fascial  attachment  laterally. 
Direct  lacerations  here  are  seldom  observed,  except  after  forceps  de- 
liveries, as  but  a  moderate  dilatation  is  required.     A  loosening  of  the 


Fig.  112. 


Flattening  of  the  Perineal  Body  in  Labor  due  to  rigidity  of  the  outlet  or  improperly  directed 

force  {%). 

p.  c,  post,  commissure  ;  e.  c.  c,  edge  constrictor  cunni ;  e.  I.  v.,  edge  levator  vaginae  (hymen) ; 
a.,  anus  ;  e.  I.  a.,  edge  levator  anl ;  e.  I.  c,  edge  levator  coceygei ;  e.  c, edge  coccygeus ;  e.  s.  s.  Z;,  edge 
smaller  sacro-sciatic  ligament. 

reflected  obturator  fascia  about  the  white  line,  sometimes  occurs  on 
one  side.  Contusion  from  the  blade  of  the  forceps,  or  a  diffuse  uni- 
lateral laceration  of  fibres  are  the  usual  forms. 

The  Levator  Coceygei. 
The  levator  coceygei  fibres  may  be  lacerated  by  forceps  blades,  by 
extension  backward  from  the  levator  ani,  or  by  a  general  overdistension 
from  a  large  head,  abnormal  mechanism,  malposition,  etc.  A  slight 
laceration  is  often  sufficient  to  relax  the  anterior  edge  and  save  the 
posterior  fibres  unless  the  forceps  blades  project,  or  labor  be  completed 
too  rapidly. 


164         LACERATION    OF    THE   PERINEUM    AND    PELVIC   FLOOR. 

The  Plane  of  the  Levator'  Ani  Proper. 

From  the  coccyx  forward  to  the  anus  extends  the  true  levator  ani. 
Its  anterior  edge  can  generally  be  felt  during  labor  by  a  little  manipu- 
lation and  careful  palpation  a  little  lower  than  that  of  the  levator 
coccygei,  and  going  to  the  sphincter  ani.  This  portion  is  but  seldom 
deeply  lacerated,  for  it  is  not  only  powerful  enough  to  resist  a  too  rapid 
dilatation,  but  its  dilatation  commences  early  or  before  the  head  gets 
far  enough  down  to  be  delivered  suddenly.  And  as  it  is  dilated  during 
rotation  of  the  head,  it  is  usually  lacerated  laterally  instead  of  at  its 
median  attachment — either  by  the  occiput  upon  one  side  or  the  parietal 
protuberance  on  the  other.  The  tear  usually  commences  at  or  in  front 
of  the  ring  and  extends  backwards  beside  the  rectum,  and  occasionally 
into  it.  In  fact  the  majority  commence  in  the  levator  vaginae  and  will 
be  considered  in  connection  with  lacerations  of  that  muscle. 

Plane  of  the  Levator  Vaginse.  or  Vaginal  Sphincter. 

The  ring  corresponding  to  the  inferior  edge  of  the  levator  vaginae  or 
vaginal  sphincter  is  the  most  easily  felt  of  any,  after  the  fetal  parts 
have  begun  to  dilate  it,  and  may  be  felt  to  reach  from  the  posterior 
surface  of  the  pubic  bone  a  little  at  one  side  of  the  median  line,  around 
the  occiput  in  an  almost  complete  circle  to  the  other  side. 

Being  the  shortest  muscle  that  completely  surrounds  the  emerging 
head,  and  at  the  same  time  so  intimately  connected  with,  and  supported 
by,  the  perineal  septum  and  deeper  pelvic  fascia,  the  levator  vaginae  is 
frequently  the  starting-point  of  deep  and  complicated  lacerations.  On 
account  of  the  lateral  position  of  the  occiput  the  greatest  strain  is 
brought  to  bear  upon  it,  as  upon  the  levator  ani  at  the  sides.  If,  then, 
a  laceration  occurs  before  the  head  has  rotated  to  a  median  position,  it 
will  be  at  one  side ;  if  it  be  delayed  until  after  that  time,  the  strain 
will  be  equalized  and  the  tear  will  occur  along  the  median  line  raphe. 
If  the  levator  vaginae  resists  rupture  and  yet  remains  but  little  dilated, 
until  the  occiput  has  rotated  to  the  centre,  a  diastasis  of  the  different 
muscles  antero-posteriorly  is  apt  to  occur.  Fig.  112  represents  about 
the  limit  of  the  separation  of  the  rings  representing  the  anterior 
edges  of  the  muscles  before  they  must  be  torn  apart.  Thus  we  may 
have  a  transverse  laceration  or  antero-posterior  diastasis  of  the  levator 
vaginae  either  from  the  levator  ani  behind,  or  from  the  perineal  septum 
and  constrictor  cunni  in  front.  It  follows,  of  course,  that  if  the  rings 
of  the  levator  ani  and  levator  vaginae  be  sufhciently  dilated  before  the 
larger  presenting  diameters  engage  in  them,  as  in  Fig.  Ill,  these  trans- 
verse lacerations  will  never  occur,  and  the  lateral  ones  very  seldom. 
As  the  lacerations  at  one  side  of  the  median  line  through  the  levator 
vaginae  always  swerve  toward  tlic  median  line,  I  shnll  call  them  diago- 
nal lacerations. 


PLANE    OF   THE    LEVATOE    VAGIX^   OR   VAGINAE   SPHINCTER.       165 

The  diagonal  lacerations,  if  they  occur  before  an  ample  dilatation 
of  the  levator  ani,  may  extend  back  into  that  muscle,  beside  or  into 
the  rectum,  or  forward  into  the  fourchette.  It  is  quite  common  for 
the  levator  vaginaB  and  levator  ani  to  become  bruised  and  weakened, 
but  to  remain  intact  until  the  head  has  rotated  pretty  well  to  a  median 
position,  and  then  to  split  back  diagonally  on  both  sides,  somewhat 
farther  and  deeper  on  one  side  than  the  other.  A  V  is  thus  formed 
which  is  usually  converted  into  a  Y  by  an  extension  along  the  median 
line  through  the  median  line  raphe.  Sometimes  one  side  of  the  Y  is 
so  short  as  to  be  scarcely  noticeable,  and  we  have  an  imperfect  f. 

When  a  diagonal  laceration  of  one  side  extends  into  the  perineal 
body  it  may,  if  the  extension  be  gradual,  assume  the  character  of  a 
flap  laceration,  and  present  a  sort  of  S-shape  when  drawn  together. 

V 

Fig.  113. 

tz-reilzra. 


■7\^  anus 

Diagonal  Flap  Laceration,  left  side  (unilateral),  drawn  together, 
c,  fourchette  ;  6,  position  of  rupture  into  levator  vaginae  ;  d,  lower  end  of  laceration  externally 
in  the  skin  ;  a,  vaginal  extremity  of  laceration  ;  abed,  line  of  superficial  laceration  ;  a  I  d,  bottom 
of  laceration  under  the  flap.  The  flap  may  be  raised  beyond  this  line.  When  the  parts  are  not 
drawn  together  the  interrupted  line  aid  is  xisually  drawn  toward  the  sound  side  beyond  the 
median  line. 

It  occurs  in  about  the  following  manner:  The  head  produces  a  super- 
ficial diagonal  laceration  and  then,  in  rotating,  strips  up  the  mucous 
membrane  and  the  contiguous  fibrous  tissue  to  or  beyond  the  median 
line,  at  the  same  time  that  it  deepens  the  lesion  diagonally  backward. 
After  having  come  to  press  more  centrally  the  head  ruptures  the  con- 
strictor cunni  a  little  nearer  the  median  line,  and  then  having  rotated 
to  the  middle  extends  the  laceration  either  directly  into  the  raphe,  or 
through  the  trans  versus  perinei  into  it,  and  out  through  the  external 
skin. 

Thus  a  large  flap  is  raised  and  an  oblique  as  well  as  diagonal  lacera- 
tion is  produced.  Fig.  113  represents  the  laceration  when  the  parts 
are  brought  together  after  labor.  ^  6  c  is  the  rent  along  the  vulvo- 
vaginal surface,  and  represents  the  portion  which  was  within  the 
vulval  orifice  and  in  contact  with  the  head.      C  d  is  the  cutaneous 


166         LACERATION    OF    THE    PERINEUM    AND    PELVIC    FLOOR. 

surface,  b  is  the  point  on  the  ring  of  the  levator  ani,  and  c  the  point 
on  the  ring  of  the  constrictor  cunni.  The  interrupted  line  indicates  the 
bottom  of  the  tear.  Thus  the  upper  end  is  through  the  levator  vaginae 
and  sometimes  the  levator  ani,  the  middle  portion  slants  through  the 
constrictor  cunni  and  sometimes  the  transversus  perinei  to  the  raphe, 
while  the  external  end  is  partly  in  the  median  line.  As  the  tear  com- 
mences before  much  dilatation  of  the  lower  end  of  the  parturient  canal, 
it  is  apt  to  be  deep  and  destructive,  and  yet  to  present  quite  an  inno- 
cent appearance,  for  the  flap  drops  into  the  wound  and  partly  covers 
it  up. 

Schatz  has  described  a  laceration  of  the  levator  vaginee  et  ani  at 
their  bony  pubic  attachments.*  I  have  often  noticed  the  falling  away 
of  the  tissues  at  the  pubic  attachment,  alluded  to  by  him,  but  have 
almost  invariably  found  the  condition  due  to  extreme  relaxation  or  to 
a  laceration  at  some  distance  from  the  bone.  This  falling  away  of 
tissue  at  one  side  is  quite  common,  laceration  at  the  bony  attach- 
ment exceedingly  rare.  The  transverse  lacerations  behind  the  levator 
vaginae  are  usually  submucous,  and  are  more  of  the  character  of  an 
attenuation  of  the  submucous  tissues ;  those  in  front  of  the  muscle  are 
apt  to  be  accompanied  by  one  or  more  of  the  other  varieties.  For 
instance,  as  the  constrictor  cunni  and  levator  vaginae  are  separated  by 
the  transverse  rupture  of  the  raphe,  the  head,  suddenly  relieved  of  a 
part  of  the  resistance,  produces  a  slight  backward  diagonal  laceration 
at  one  side,  or  both,  and  then,  in  passing  the  vulva,  produces  a  median 
laceration  forward.     If  such  a  laceration  is  drawn  together  a  peculiar 

figure  is  produced       I      .     If  the  levator  ani  give  way  in  the  median 

line,  as  is  apt  to  be  the  case  after  the  head  has  got  so  far  down,  the  re- 
sulting figure  would  be  an  inverted  T  J_ ,  which  by  extension  may  be 
converted  into  a  cross  -}-.  Or,  if  the  median  laceration  of  the  levator 
vaginae  be  fan-shaped,  we  have  a  fan  upon  a  transverse  line  ^^  .    By  an 

extension  into  the  vulva  the  fan  may  get  a  handle  y  .  The  V-  or  Y- 
shapes  may  also  occur  with  the  transverse  and  give  rise  to  correspond- 
ing figures  -^  -_/-.     If  the  transverse  rent  be  unilateral,  half  of  these 

figures  ma}^  be  produced  with  half  of  the  transverse  line  wanting  p-. 

When  a  V-shaped  laceration  occurs  before  the  transverse,  the  trans- 
verse laceration  through  the  raphe  may  be  merely  represented  on  the 
surface  by  a  deepening  and  widening  of  the  V,  especially  about  its 
angle.   A  transverse  laceration  accompanied  by  a  short  diagonal  lacera- 

*  Op.  cit. 


THE   VULVAL   PLANE    OR    RmG.  167 

tion  backward  at  either  end  may  assume  the  shape  of  a  crescent  or 
bow. 

When  the  head  rotates  to  the  median  line  before  lacerating  the 
levator  vaginse,  we  may  get  a  superficial  laceration  in  or  about  the 
median  line  either  single  or  fan-shaped,  with  or  without  an  extension 
through  the  vulva.  These  are  apt  to  commence  at  the  constrictor 
cunni  and  extend  backward  and  forward. 

Plane  of  the  Constrictor  Cunni  or  Vulval  Sphincter. 

The  constrictor  cunni  or  vulval  sphincter  is  not  only  longer  than 
the  levator  vaginae,  but  is  less  intimately  connected  with  the  deeper 
muscles  and  fascia,  and,  therefore,  is  normally  more  easily  dilated  and 
less  frequently  ruptured.  The  ring  marking  the  anterior  edge  of  the 
constrictor  cunni  is  readily  felt  by  depressing  the  softer  tissues  of  the 
labia  and  posterior  commissure  at  the  vulval  outlet,  as  the  head  re- 
cedes after  a  pain.  It  extends  from  the  anterior  surface  of  the  sym- 
physis, near  the  superior  junction  of  the  labia  minora,  to  the  four- 
chette.  When  the  vaginal  and  vulval  orifices  are  dilated  gradually  by 
a  proper  wedge,  the  fascial  union  at  the  raphe  is  maintained,  the  vul- 
val muscle  expands  with  the  vaginal,  and  is  safe  as  long  as  the  latter 
maintains  its  integrity.  But  when  there  is  no  dilating  wedge,  and  the 
muscles  are  stretched  and  flattened  over  the  presenting  part,  as  in  Fig. 
112,  the  vulval  and  vaginal  rings  become  separated,  and  the  raphe  is 
o'ver-stretched  antero-posteriorly,  or  even  torn  across.  The  ring  at  the 
constrictor  cunni  is  left  undilated,  and  when  the  levator  vaginae  gives 
way  or  becomes  sufficiently  dilated,  may  be  obliged  to  stretch  so 
rapidly  before  the  released  head  that  it  must  part  asunder.  Such  is 
usually  the  case  in  primary  lacerations  of  these  superficial  parts. 

The  great  majority  of  deep  lacerations  into  the  constrictor  cunni  are 
secondary  to  lacerations  of  the  vaginal  entrance.  When  they  occur 
primarily,  or  without  any  foregoing  lesions,  they  are  commonly 
median  lacerations,  for  they  are  produced  after  the  head  has  rotated 
to  a  central  position,  and  it  is  after  the  pressure  has  become  equalized 
that  the  strain  upon  the  perineal  tissues  centres  in  the  raphe.  Lacera- 
tions commencing  in  the  levator  vaginae  also  tend  to  be  completed 
externally  through  the  median  line.  Primary  lacerations  commenc- 
ing in  the  median  line  at  the  constrictor  cunni  may  extend  straight 
back  into  the  levator  vaginae,  but  usually  very  superficially.  Trans- 
verse lacerations  external  to  the  constrictor  cunni  occasionally  occur, 
but  are  of  little  practical  importance. 

The  Vulval  Plane  or  Ring. 

Even  when  the  parts  are  normally  relaxed  and  dilated,  the  vulval  ring 
through  the  labia  and  posterior  commissure  is  not  sufficiently  dilated 


168         LACEEATIOX   OF   THE    PERIiSrEUM   AND    PELVIC    FLOOR. 

for  the  head  to  pass  quickly,  and  unless  the  expulsive  efforts  are  mo- 
derated or  the  head  held  back,  must  usually  rupture  transversely  or 
in  the  median  line.  If  the  external  parts  be  rigid,  the  condition  rep- 
resented in  Fig.  112  results.  Thus  quite  an  extensive  superficial  rup- 
ture of  the  vulval  and  external  cutaneous  surfaces  may  occur  without 
invading  anything  else  but  fatty  connective  tissue.  But  as  the  skin  is 
the  most  extensive  and  extensible  of  all  perineal  tissues,  it  would,  if 
given  time,  seldom  lacerate  at  all. 

Lacerations  Extending  into  the  Transversus  Perinei  and  Sphincter  Ani. 

Unilateral  diagonal  lacerations  extending  out  through  the  vulva 
may  extend  through  the  transversus  perinei  at  the  side  of  the  raphe 
and  even  through  the  sphincter  ani.  The  double  diagonal  may  also 
extend  along  the  raphe  down  to  or  through  the  sphincter,  without 
necessarily  involving  the  lining  membrane  of  the  anus.  The  earlier 
the  deeper  lacerations  commence,  and  the  more  rapid  the  delivery,  the 
greater  the  liability  to  such  extension. 

Lacerations  of  the  Perineal  Septum. 

The  perineal  septum  is  nearly  always  slightly  ruptured  in  several 
places  with  the  hymen  which  fringes  its  perforated  edges.  An  early 
deep  diagonal  laceration  may  extend  forward  from  the  levator  vaginae 
through  the  hymen  and  septum,  and  so  relax  the  perineum  as  to  pre- 
vent farther  injury.  A  laceration  through  the  transversus  perinei  at 
one  side  of  the  median  line  usually  goes  through  the  lower  border  of 
the  septum  also  (see  Fig.  22)  and  thus  practically  divides  it  in  twain. 
Such  an  accident  must  of  course  completely  relax  the  whole  fascial 
circumference  of  the  vaginal  orifice  and  leave  the  lower  end  of  the 
urethra  uiisupported.  In  conjunction  with  a  laceration  through  the 
levator  vaginae  it  leaves  almost  the  whole  urethra  and  periurethral 
connective  tissue  unsupported  and  sagging  down  into  the  vulva. 

Lacerations  of  the  Deep  Pelvic  Fascia. 

The  deep  fascia  is  reflected  over  all  the  muscles,  and  is  lacerated 
with  them,  and  only  without  them  when  the  laceration  takes  the 
direction  of  the  muscular  fibres.  Hence  the  mechanism  of  the  lacera- 
tions of  the  muscles  will  suffice  for  the  fascia  also. 

The  Flap  Lacerations. 

One  of  the  most  complicated  of  the  flap  lacerations,  the  unilateral 
or  S-shaped,  has  been  described  among  the  diagonal ;  yet  almost  any 
laceration,  except  the  median,  is  liable  to  be  complicated  by  the  rais- 
ing and  displacement  of  a  flap  of  mucous  membrane  or  skin.  Such 
barking  of  the  tissues  occurs  during  the  movement  of  the  head  over  a 


CENTRAL  EUPTUEES — IRREGULAR  LACERATIONS.      16& 

superficial  laceration  that  is  slow  to  extend  into  the  deeper  tissues^ 
and  particularly  so  if  the  line  of  the  tear  makes  a  curve  or  an  angle. 
The  tongue  of  vaginal  tissue  in  the  V-shaped  laceration  is  sometimes 
stripped  back  enough  to  allow  of  considerable  retraction.  The  pro- 
jecting parts  in  angular  tears,  or  tears  crossing  one  another,  as  when 
a  transverse  laceration  is  compounded  by  an  antero-posterior,  may  be 
stripped  back  by  the  head  if  it  advances  before  extending  the  lacera- 
tion deeper. 

The  deep  or  essential  part  of  the  tear  does  not  always  correspond 
with  the  superficial  lesion,  and  the  displaced  flap  may  be  retracted 
from  where  it  belongs  and  grow  over  and  into  the  lacerated  surface, 
and  thus  converts  deep  structures  into  submucous  tissue.  They 
show  how  mistakes  may  be  made  in  depending  entirely  upon  the 
cicatrices  for  the  diagnosis  of  lacerations. 

Central  Ruptures. 

Ruptures  through  the  perineal  centre,  leaving  an  untorn  bridge  of 
tissue  about  the  fourchette  or  posterior  commissure,  are  usually  a 
combination  of  lacerations,  extending  in  various  directions.  They 
occur  when  the  vulval  rings  are  rigid,  and  hold  up  the  fourchette 
while  the  head  is  driven  rapidly  against  the  perineal  centre.  When 
the  advance  of  the  head  is  arrested  before  being  driven  through  the 
perineal  centre,  it  may  be  made  to  pass  through  the  vulva  over  the 
untorn  bridge  of  tissue.  This  is  especially  the  case  if  the  central 
rupture  be  produced  by  a  projecting  foot,  knee,  or  elbow,  that  can  be 
pushed  up  out  of  the  way. 

According  to  Charpentier,*  who  collected  the  reports  of  fifty-six 
cases,  the  factors  in  their  production  are  : 

1.  Exaggerated  height  of  the  symphysis  pubis. 

2.  Condition  of  the  perineum,  viz.,  smallness  and  rigidity. 

3.  Irregularity  and  exaggerated  intensity  of  the  painsv. 

Irregular  Lacerations. 

When  the  vulval  and  vaginal  rings  remain  long  midilated,  so  that 
the  perineum  becomes  stretched  over  the  head  like  a  membrane,  the 
maternal  structures  involved  may  finally  lose  all  of  their  normal 
characteristics,  and  burst  in  a  stella^te  or  otherwise  irregular  manner, 

producing,  when  drawn  together,  all  sorts  of  figures,  -4  p  X-VV  J. 

Such  forms  are  generally  accompanied  by  considerable  bruising  of  the 
parts,  and  show  but  little  tendency  to  primary  union  of  surfaces,  but 
on  the  other  hand  are  ajDt  to  cicatrize  extensively,  and  leave  a  very 
firm,  although  small  and  mutilated,  perineal  body. 

*  Archives  de  Tocologie,  November  and  December,  1885. 


170         LACERATION    OF   THE    PERINEUM    AND    PELVIC    FLOOR. 

Concealed  Lacerations. 

Lacerations  of  the  deeper  structures,  that  do  not  involve  the  skin 
or  mucous  membrane,  are  almost  invariably  of  the  transverse  variety, 
or  are  made  up  of  a  number  of  minute  lacerations  in  the  muscular 
fibres  and  fasciffi  over  a  limited  (but  not  linear)  area,  or  over  a  half 
or  the  whole  of  the  perineum  or  pelvic  floor.  This  latter  is  the  diffuse 
variety  due  to  over-distension,  and  may  thus  be  regional  or  general. 

The  reason  why  the  diagonal  or  transverse  lacerations  scarcely  ever 
occur,  without  involving  the  mucous  membrane  or  skin,  is  because 
internally  the  levator  vaginae  is  so  intimately  connected  with  the 
vaginal  wall,  that  they  must  tear  together ;  and  externally  the  parts 
become  so  flattened  and  pressed  together  before  laceration  primarily 
occurs,  that  the  vulval  skin,  if  not  the  external,  must  rupture  with 
the  raphe.  I  have  sought  scores  of  times  for  a  submucous  or  subcu- 
taneous parting,  or  diastasis,  of  the  muscles  and  fascia  in  the  median 
line  raphe,  but  have  never  yet  failed  to  find  evidence,  either  of  a 
co-existing  superficial  laceration,  or  else  of  the  unbroken  attachment 
of  the  muscles  to  the  median  line.  When,  however,  a  laceration  re- 
mains uncicatrized,  the  new  skin  or  mucous  membrane  is  apt  to  make 
it  appear  subcutaneous  or  supravaginal.  Difi'use  laceration  and  re- 
laxation also,  in  consequence  of  the  falling  away  at  the  sides,  gives  a 
deceptive  appearance  of  diastasis  along  the  median  line.  An  unusual 
mobility  and  flabbiness  of  the  rectum  is  also  apt  to  give  the  inexpe- 
rienced a  notion  of  the  parting  of  muscles. 

But  strangely  enough  the  condition  that  is  usually  mistaken  for 
such  a  laceration  is  one  which  extends  transversely  through  the  raphe 
between  the  levator  vaginse  and  constrictor  cunni,  and  leads  to  a 
diastasis  of  these  muscles  for  each  other  along  the  transverse  tear. 
The  levator  vaginae  is  thus  separated  from  the  lower  perineal  tissues, 
relaxing  the  vulval  and  rectal  sides  of  the  perineal  body,  and  leaving 
the  cutaneous  side  to  sustain  the  full  force  of  the  abdominal  pressure. 
As  a  consequence  the  constrictor  cunni  relaxes  until  it  lies  against 
the  pubic  ramus  like  a  retracted  curtain,  and  allows  the  loosened  rec- 
tum, covered  by  the  attenuated  vaginal  wall,  to  bulge  over  the  sagging 
fourchette.     The  levator  vaginse  is  drawn  up  but  not  lacerated. 

More  or  less  diffuse  laceration  jarobably  occurs  in  the  great  majority 
of  first  labors.  In  the  levator  ani  it  may  occur  along  the  course  of 
the  occiput  in  occipito-posterior  deliveries  or  of  the  forehead  in  nor- 
mal presentations  of  a  large  head.  It  may  involve  any  one  of  the 
planes  of  the  perineum  or  pelvic  floor  of  one  or  both  sides,  or  even 
the  whole  perineum  and  pelvic  floor,  as  during  capping  of  the  head. 
The  muscular  fibres  lacerate  separately  and  irregularly  throughout 
the  given  area  like  the  rubber  threads  in  a  worn-out  elastic  suspender. 
The  skin  or  mucous  membrane  is  seldom  lacerated  to  any  extent  in 
any  one  place,  although  it  may  present  slight  abrasions  or  lesions. 


IMMEDIATE  EFFECTS  OR  THOSE  INCIDENT  TO  PUERPERAL  STATE.    171 

Contusions  about  the  Bony  Walls. 

Contusions  about  the  bony  walls  ordinarily  involve  the  mucous 
membrane  and  vulval  skin  and  their  underlying  connective  tissue. 
They  result  from  pressure  of  the  head  during  its  passage.  The  mem- 
brane may  be  stripped  from  its  base  in  several  different  places.  J. 
Matthews  Duncan  in  one  case  counted  as  many  as  eight  separate 
lacerations  of  the  vagina,  perineum,  and  vulva. 

Lacerations  Extending  into  the  Rectum. 

A  laceration  extending  into  the  rectum  seldom  commences  as  a 
median  one,  for,  as  the  head  must  have  rotated  under  the  pubic  arch 
before  a  median  laceration  can  occur  (excluding  those  which  are  ex- 
tensions of  the  diagonal  or  transverse  varieties),  the  rectum  will  usually 
be  pushed  back  out  of  the  way  before  the  tear  begins.  Generally  a 
single  or  double  diagonal  laceration  occurs,  first  involving  the  levator 
vaginae,  and  extending  into  the  edge  of  the  levator  ani  of  one  side  at 
least,  and  so  exposing  the  rectum.  The  head,  bearing  through  the 
rent  toward  the  anus,  flattens  the  perineum,  including  the  sphincter 
arii,  and,  as  it  rotates  to  the  centre,  splits  the  remaining  perineal 
structure  through  or  beside  the  raphe,  down  into  the  rectum  and  out 
through  the  anus  and  skin.  A  large  head  delivered  rapidly  by  for- 
ceps is  apt  to  drag  down  the  rectum  and  lacerate  into  it. 

>  Effects  of  Perineal  and  Pelvic  Floor  Lacerations. 

The  immediate  effects  of  pelvic  floor  and  perineal  laceration  vary 
greatly  according  to  the  amount  of  injury  done,  while  the  remote 
effects  depend  less  upon  the  amount  of  injury  than  upon  the  subse- 
quent repair  brought  about  by  an  immediate  union,  or  by  the  process 
of  cicatrization. 

The  Immediate  Effects  or  those  Incident  to  the  Puerperal  State. 

The  ijnmediate  effects  are  a  weakening  of  all  pelvic  tissues  by  a  des- 
truction of  the  inferior  stay  to  the  pelvic  viscera,  and  thus  a  removal  of 
that  support  which  the  inferior  portion  of  the  connective-tissue  frame- 
Avork  and  their  inclosed  viscera  afford  by  contiguity,  to  those  above  it. 
In  addition  to  this  the  direct  support  which  is  afforded  by  the  pelvic 
floor  to  the  puerperal  uterus,  until  it  becomes  small  and  light  enough 
to  be  held  up  by  the  superior  or  pelvic  roof  structures,  is  weakened 
and  sometimes  partly  taken  away. 

As  a  result  congestion  of  the  uterus  and  pelvic  viscera,  delayed  or 
arrested  involutions,  loss  of  control  over  the  rectal  and  vesical  dis- 
charges, a  general  weakening,  and  an  inability  to  assume  with  comfort 
the  sitting  or  erect  postures  within  a  natural  period  are  frequently 
noticed.     When  the  rectum  is  opened  the  subsequent  alvine  discharges 


172        LACERATIOX    OF    THE    PERIXEUM    AND    PELVIC    FLOOR. 

are  apt  to  increase  and  prolong  the  inflammation  and  suppuration 
about  the  lacerated  surfaces  and  so  give  rise  to  a  state  of  great  suffering. 
I  knew  one  young  woman  to  commit  suicide  within  two  weeks  after 
confinement  to  escape  her  misery. 

Other  secondary  results,  such  as  septicaemia,  inflammation  of  the 
neighboring  connective  tissue,  etc.,  belong  to  such  wounds,  as  to  those 
which  occur  elsewhere. 

Remote  Effects. 

Were  there  no  attempts  at  repair  on  the  part  of  nature,  the  remote 
effects  of  injuries  to  the  parturient  canal  would  be  sad  indeed.  For- 
tunately they  are  nearly  all  repaired  to  a  certain  extent,  so  that  but  a 
small  percentage  of  them,  except  those  which  open  into  the  rectum, 
give  rise  to  much  trouble  afterward.  And  now  that  the  accoucheur  is 
learning  how  to  repair  them  immediately,  the  cases  left  for  subsequent 
treatment  may  be  expected  in  the  near  future  to  appreciably  diminish. 

Among  150  consecutive  gynecological  cases  among  childbearing 
women  examined  in  my  office,  the  perineum  was  carefully  inspected 
in  all  but  seven,  viz. :  in  143.  Evidences  of  laceration  were  dis- 
covered in  all  but  eight  (135).  Of  this  number  all  but  ten  lacerations 
had  cicatrized.  Of  the  125  that  had  cicatrized  only  five  were  operated 
upon,  and  not  more  than  five  others  seemed  to  require  it.  Of  the  ten 
uncicatrized,  five,  or  all  except  the  very  slight  ones,  required  an  opera- 
tion. About  twenty-five  per  cent,  of  the  lacerations  were  slight,  in- 
volving only  the  vulva  superficially  or  the  edge  of  the  levator  vaginae 
of  one  side.  It  was  thus  determined  that,  no  matter  how  extensive  the 
laceration,  if  it  did  not  involve  the  sphincter  ani,  there  was  seldom  a 
sufficient  displacenaent  of  parts  in  those  cases  in  which  cicatrization 
had  occurred  to  require  an  operation,  Avhile  all  lacerations  of  an}'- 
extent  which  were  not  cicatrized  required  an  operation.  In  two  cases 
the  external  anal  sphincter  was  lacerated,  once  entirely  through  to  the 
mucous  membrane,  yet  the  cicatricial  tissue  acting  in  conjunction  Avith 
the  internal  sphincter  and  levator  ani  gave  the  patients  control  of  their 
evacuations.     In  but  one  of  this  series  was  the  rectum  opened. 

Effects  upon  the  Uterus. 

After  extensive  injury  involving  the  pelvic  floor,  unless  some  kind 
of  repair  occurs,  the  uterus  remains  enlarged  and  congested,  the  vagina 
voluminous  and  lax,  and  the  connective  tissues  soft  and  but  feebly 
elastic,  and  sometimes  infiltrated  by  deposits.  As  a  consequence  the 
uterus  sinks  low  in  the  pelvis,  or  is  drawn  out  of  position  by  contract- 
ing deposits  in  the  connective  tissue. 

If  such  contracting  deposits  be  in  the  upper  part  of  the  broad  liga- 
ments the  fundus  will  be  drawn  towards  the  same  side,  forward  or 
backward  according  as  it  extends  along  the  round  ligaments  or  back- 


EFFECT    UPON    THE    BLADDEE,    URETHEA,    AND    EECTUM.       173 

wards  over  the  infundibulo-pelvic  ligament.  If  the  deposit  be  about 
the  cervix  in  the  sacro-uterine  ligaments,  the  cervix  will  be  drawn  up- 
wards and  backwards,  and  the  fundus  pressed  downwards  and  forwards 
over  the  bladder  by  abdominal  pressure  (Fig.  53).  If  the  deposit  be 
in  the  vesi co-vaginal  septum  or  anterior  layer  of  the  broad  ligament, 
the  cervix  will  be  drawn  forward  or  to  one  side,  and  the  fundus  in 
some  cases  pressed  by  abdominal  pressure  back  against  the  sacrum. 
The  inefficiency  of  the  pelvic  floor,  or  secondary  support  to  the  uterus, 
not  only  throws  the  weight  of  the  organ  but  also  the  entire  abdominal 
pressure  upon  these  inflamed  and  rigid  supports.  The  effect  is  often 
disastrous,  and  renewed  attacks  of  inflammation  follow  every  attempt 
at  active  exercise. 

As  the  superior  uterine  supports  are  only  firm  enough  to  hold  the 
uterus  in  position  while  the  involuntary  or  constant  abdominal  pres- 
sure is  equalized  by  an  efficient  perineum  and  pelvic  floor,  extensive 
injury  of  these  parts  unaccompanied  by  inflammatory  deposits  or 
compensating  cicatrices  will  allow  the  uterus  to  sink  upon  the  bladder, 
or  the  cervix  to  slide  downward  and  forward  and  stretch  the  sacro- 
uterine ligaments,  until  either  the  os  uteri  appears  at  the  gaping  vulva, 
or  the  abdominal  pressure  comes  to  bear  upon  the  anterior  surface  of 
the  uterus  and  turns  the  fundus  back  against  the  holloAV  of  the  sacrum. 
Sometimes  the  uterus  remains  unusually  movable  and  at  one  examina- 
tion may  be  found  with  the  fundus  against  the  sacrum,  and  at  another 
with  the  fundus  behind  the  symphisis  pubis.  In  extreme  cases  the 
subinvoluted  uterus  finds  its  way  out  into  or  entirely  beyond  the 
vulva. 

Effect  iqwn  the  Bladder,  Urethra,  and  Rectum. 

When  the  head  becomes  deeply  engaged  in  the  pelvic  cavity  before 
the  external  os  is  sufficiently  dilated  to  allow  the  structures  about  the 
pubo-uterine  ligaments  to  be  drawn  up,  the  bladder  and  urethra  are 
liable  to  be  caught  between  the  head  and  the  pubes  and  either  dragged 
loose  from  their  attachments,  or  directly  lacerated,  or  else  so  contused 
that  the  tissues  will  part  asunder  from  the  force  of  mere  pressure,  or 
in  consequence  of  subsequent  necrosis.  If  now  the  perineal  and  pelvic 
floor  support  to  the  abdominal  pressure  be  to  any  considerable  extent 
removed,  the  bladder  will  be  forced  by  the  direct  abdominal  pressure 
down  behind  and  under  the  pubic  arch  and  remain  there  in  a  state  of 
congestion. 

Similarly  if  the  perineal  raphe  be  torn  entirely  through,  the  rectum 
may  be  forced  by  the  reflected  abdominal  pressure  into  the  vulva.  In 
either  case  the  pressure  exerted  through  the  prolapsed  viscera  prevents 
efficient  cicatrization,  and  particularly  so  if  the  patient  be  allowed  to 
sit  up  before  the  cicatrix  can  form  and  contract. 


174         LACERATION    OF    THE   PERINEUM    AND    PELVIC    FLOOR. 

Effects  upon  the  Vagina. 

Subinvolution,  chronic  congestion,  plastic  enlargement  and  increased 
weight  of  the  vaginal  walls  are  also  the  results  of  the  lacerations  in 
question.  And  not  only  does  this  weighty  and  redundant  tissue  find 
its  own  way  out  of  the  vulva,  but  it  drags  upon  the  uterus,  bladder 
and  rectum,  and  aids  in  bringing  about  that  complete  series  of  changes 
in  the  pelvic  viscera  whose  final  sequence  is  a  lodgment  of  the  pelvic 
organs  entirely  outside  of  the  body. 

Cicatrices  in  the  vagina  and  supra-vaginal  connective  tissue  may 
not  only  prevent  prolapse  of  the  vaginal  walls  but  may  draw  them 
higher  up  in  the  j^elvis.  But  as  the  cicatrix  will  thus  have  both  the 
weight  of  the  vagina,  and  perhaps  the  uterus  and  abdominal  pressure 
to  bear,  the  patient  may  suffer  more  than  if  such  cicatricial  support 
did  not  exist. 

Other  Effects. 

Thus  cicatrices  of  large  size  may  be  sometimes  sensitive  and  trouble- 
some on  account  of  traction  and  pressure  upon  them,  particularly  so 
if  previous  hypereesthesia  or  tenderness  have  existed.  Reflex  pehdc 
pains  and  discomfort  have  been  traced  to  them.  Yet  when  primary 
union  does  not  take  place  cicatrization  is  desirable  as  a  healing  process, 
and  as  a  prevention  of  displacement  of  the  structures  above  it. 

Sterility  from  a  want  of  retention  of  the  semen,  and  impotence  from 
a  want  of  copulative  power,  attend  only  upon  the  rare  and  severer 
forms  of  lacerations.  The  levator  ani  is  the  chief  muscle  concerned  in 
the  copulative  act,  and  is  scarcely  ever  sufficiently  involved  to  be  thus 
functionless  unless  the  rectum  be  laid  open.  Laceration  through  the 
external  sphincter  but  not  through  the  mucous  membrane  of  the  rectum 
is  not  as  serious  as  would  be  supposed,  since  the  levator  ani  and  internal 
sphincter  ani  aided  by  the  cicatrix  about  the  anus  often  aflFords  satis- 
factory retentive  power.  Even  when  the  internal  sphincter  is  torn 
through,  the  levator  ani  aided  by  a  firm  cicatrix  may  enable  the  patient 
to  control  all  but  liquid  or  semi-liquid  passages. 

Symptoms  of  Perineal  and  Pelvic  Floor  Lacerations. 

The  symptoms  of  immediate  lacerations  are  great  soreness  of  the 
parts  to  the  touch  immediately  after  labor,  painful  defecation  and 
micturition,  and,  if  the  rectum  has  been  opened,  incontinence  of  faeces. 
Occasionally  hemorrhage  may  give  rise  to  symptoms  of  weakness  and 
prostration.  Later  on  symptoms  of  local  or  general  pysemic  infection 
may  occur  as  after  wounds  in  general.  (See  Effects  of  Perineal  and 
Pelvic  Floor  Lacerations,  above.) 

Secondary  Symptoms. 

After  the  wounded  surfaces  have  healed,  the  most  characteristic 
symptoms  are  those  belonging  to  imperfect  involution  of  the  parts, 


VAEIETIES    OF    LACEEATIOJST. 


175 


viz.,  leucorrhoea,  constipation  or  else  an  inability  of  the  rectum  to  com-  ^ 
pletely  expel  the  faeces,  hemorrhoids,  weakness  or  irritability  of  blad- 
der, feeling  of  weight  about  the  pelvic  outlet,  a  want  of  general  strength, 
reflex  nervous  symptoms,  etc.  Lacerations  of  the  perineum  allowing 
of  prolapse  or  inversion  of  the  parts  are  attended  by  local  irritation, 
ulceration,  and  the  formation  of  soft  projections  between  the  labia ; 
those  of  the  pelvic  floor  sufficient  to  take  away  a  part  of  its  support  to 
the  pelvic  connective  tissue  give  rise  to  such  symptoms  as  are  usually 
connected  with  a  sinking  of  the  pelvic  organs  below  their  normal 
plane.  A  strained  or  sore  condition  of  the  superior  or  pelvic  roof 
supports,  and  a  displacement  of  the  pelvic  organs  are  common 
symptoms. 

In  making  the  examination  of  a  patient  complaining  of  symptoms 
which  we  recognize  as  due  to  pelvic  diseases,  we  should  by  palpation 
and  if  necessary  by  inspection  always  investigate  the  condition  of  the 
pelvic  floor  and  perineum  as  a  possible  direct  or  indirect  cause  of 
some  of  them. 

Varieties  of  Laceration. 

A  careful  examination  of  the  displacements  and  cicatrices  in  the 
series  of  cases  already  referred  to  was  made,  and  the  following  table 
constructed : 


Median  laceration,  slight  and  extensive  (  j  j,   . 

Right  diagonal  (\  ),  through  right  levator  vaginfe, 

Left  diagonal  (  /),  through  left  levator  vaginae, 

Double  diagonal  or  \V  -shaped  through  both  levator  vaginae, 

Double  diagonal  with  forward  extension,     y -shaped, 

Right  diagonal  with  forward  extension,  an  incomplete  Y  (    \  j, 

Left  diagonal  with  forward  extension,  an  incomplete  Y  (  /  ),    . 
Diagonal  fan-shaped  (^^^  ),....... 

Diagonal  fan-shaped,  with  forward  extension  (    N'    )>    - 

Left  diagonal  flap  laceration,  the  S-shape  (  \    ))       • 

Right  diagonal  flap  laceration,  the  S-shape  f  /  j,    . 

Transverse  (— — ), 

Transverse  with  median  forward  or     |   -shaped, 
Transverse  with  median  backward  or  inverted  T  ( J_),    • 
Transverse  with  median  backward  and  forward,  or  cross  shaped  ("t") 
Transverse  across  double  diagonal  ( \/     ),        .... 


25 

17 

13 

10 

15 


176         LACERATIOX    OF   THE    PERINEUM    AND    PELVIC    FLOOR. 

Transverse  across  double  diagonal  with  median  extension  (     V     )       1 

Median  joined  to  left  diagonal  (Y), 2 

Median  and  left  diagonal  separate  (  )> 1 

Eight  transverse  with   median  forward  and  backward,  crossed  by- 
right  ant€ro-posterior  backward  (  ■II'  ),     .         .         •         .         .1 

Transverse  joined  at  right  with  diagonal  (  \__  ),   .         .         .         .       1 
Transverse  joined  at  right  and  left  with  diagonal,  and  centrally  with 

stellate  (\-^^), 1 


Median  joined  to  I'ight  diagonal  and  right  transversely  -H   ), 


1 
131 


However  cumbersome  such  a  verbose  nomenclature  of  perineal 
lacerations  may  at  first  sight  appear,  a  close  examination  of  the  figures 
will  show  how  an  accurate  differentiation  cannot  be  made  of  such  a 
combination  of  cicatrices  without  a  corresponding  combination  of 
terms.  To  students  and  beginners  such  a  detailed  nomenclature  must 
be  of  value  as  giving  a  more  definite  idea  of  the  nature  of  such  lacera- 
tions than  by  merely  dividing  them  into  degrees  according  to  their 
extent,  but  without  reference  to  their  character.  In  ordinary  descrip- 
tions they  may  be  designated  as  the  median,  the  diagonal,  the  trans- 
verse, the  central,  and  compound^such  as  the  V  shaped,  Y  shaped, 

inverted  T  (  J_  ),  cross  (  -f-  )?  double  cross  (  Tj"  ),  L,  fan  shaped, 

imperfect  Y   f  f     J ,  etc. 

When  tbe  tear  extends  into  the  rectum  the  same  characters  can  often 
be  discovered  and  named  in  connection  with  a  mention  of  the  exten- 
sion into  the  rectum  in  order  to  be  properly  classified.  These  are  also 
called  the  complete  lacerations,  those  not  opening  into  the  rectum  the 
incomplete  or  partial  ones. 

Degrees  of  Laceration. 

The  degree  of  laceration  can  best  be  made  ititelligible  by  mention- 
ing the  structures  involved. 

In  median  ruptures  the  cutaneous  portion  of  the  raphe  may  alone 
be  lacerated  down  to  the  sphincter  ani  or  through  it,  or  into  the  rec- 
tum ;  or  only  the  vulv'al  portion,  or  fourchette  may  be  involved ;  or 
only  the  vaginal  portion  (the  recto-vaginal  septum)  ma}'  be  torn  a 
given  distance  beyond  the  hymen;  or  two  or  all  of  these  portions. 
Again,  the  skin  or  mucous  membrane  may  alone  be  torn,  or  the  raphe 
may  be  slightly  involved,  or  ruptured  through,  to  or  into,  the  anal  and 
rectal  mucous  membrane,  for  any  given  distance.     Antero-posterior 


DIAGNOSIS    OF    PERINEAL    AND    PELVIC-FLOOR    LACERATIONS.       177 

lacerations  to  one  side  of  the  median  line  maj'  involve  the  hymen  or 
perineal  septum,  the  levator  vaginse,  the  constrictor  cunni,  transversus 
perinei,  the  cutaneous  surface,  rectum,  one  or  all. 

The  transverse  lacerations  may  be  to  the  right  or  left  of  the  median 
line,  or  entirely  across  from  one  pubic  fossa  to  the  other.  They  may 
extend  barely  through  the  skin  or  mucous  membrane,  or  partly  or  quite 
through  the  raphe.  Or  they  may  be  external  or  internal  to  the  vaginal 
or  vulval  sphincter,  or  perineal  septum. 

The  diagonal  lacerations  may  partly  or  completely  sever  one  or  both 
levatores  vaginse,  and  the  hymen  or  edge  of  the  perineal  septum ;  or 
the  transversus  perinei;  or  may  extend  into  the  edge  of  the  levator  ani ; 
or  may  extend  to  or  into  the  rectum. 


Diagnosis  of  Perineal  and  Pelvic-floor  Lacerations. 

I.  Of  the  Recent  Lacerations. — As  after  prolonged  labor  the  perineum 
remains  relaxed  for  a  short  period,  a  flabby  or  large  vulvo-vaginal 
outlet  is  of  little  importance  as  evidence  of  laceration,  unless  the  sec- 
ond stage  has  been  short,  or  unless  the  enlarged  state  of  the  outlet 

Fig.  115. 


C 

Triangular  Lacerations  (schematic). 
V,  vaginal  end;  I,  labia  or  the  sides  ;  c,  cutaneous  end.  The  interrupted  line  vc  represents  the 
bottom  of  the  laceration  or  common  base  of  the  triangles.  Half  of  the  dotted  line  U  represents 
the  depth  of  the  laceration  or  altitude  of  the  triangles.  The  lines  constituting  these  figures  are 
all  more  or  less  concave  or  convex  when  the  surfaces  are  in  apposition,  but  become  straight  when 
widely  separated  by  traction. 

continues  for  several  hours.  A  complaint  of  great  soreness  at  the  re- 
moval of  the  after-birth,  and  upon  the  lightest  touch  about  the  pos- 
terior commissure  and  vaginal  entrance  is  one  of  the  first  and  most 
reliable  signs.  A  light  touch  is  not  painful  to  the  parts  after  labor 
unless  there  be  a  raw  surface.  If  there  be  no  laceration  the  parts  will 
be  smooth  and  either  normal  in  relationship,  or  evenly  flattened  about 
the  fourchette  and  posterior  commissure. 

Upon  inspection  through  the  separated  labia  and  after  removal  of 
the  blood  by  a  soft  cloth  we  can  easily  detect  the  triangle  formed  by  a 
median  laceration.     The  yellowish  gleam  of  the  subcutaneous  fat,  and 

12 


178         LACERATION    OF    THE    PERINEUJI    AND    PELVIC    ELOOE. 

the  white  fibrous  tissue  of  the  raphe  are  easily  recognized,  and  may  be 
easily  traced  along  the  median  line  into  the  vagina.  Sometimes  nearly 
all  of  the  laceration  will  be  external  to  the  hymen,  or  cutaneous ;  at 
other  times  nearly  all  internal  to  it,  or  vaginal. 

The  extent  of  the  perineal  laceration  is  not  determined  by  the  length 
of  the  sides  of  the  triangle,  but  by  the  altitude  or  distance  from  a  lower 
caruncle  or  the  lacerated  edge  of  the  fourchette  to  the  bottom  of  the 
rent.  Convexity  of  the  bottom  denotes  shallowness,  concavity  denotes 
depth,  of  the  tear.  Fig.  114  is  a  long  shallow  rent  convex  at  the  bot- 
tom, Fig.  115  is  a  short  deep  one  concave  or  flattened  at  the  bottom. 
When  the  whole  lacerated  surface  is  a  uniform  expanse  of  fatty  tissue, 
the  essential  perineal  structures  are  not  involved,  no  matter  how  long, 
ragged  and  formidable-looking  the  edges ;  when  the  bottom  of  the  sur- 
face shows  the  white  torn  bands  of  connective  tissue,  or  the  reddish 
ends  of  muscular  fibres,  the  deejjer  structures  are  affected,  no  matter 
how  small  the  cutaneous  or  vaginal  lesion.  When  the  triangular  sur- 
faces are  separated  at  the  bottom  by  an  expanse  of  dark  red  or  dark 
blue  membrane,  and  are  made  up  of  the  red  muscular,  white  fibrous 
and  yellow  fatty  tissue,  the  rectum  has  been  oi3ened.  The  extent  of 
the  invasion  of  the  rectum  may  be  followed  by  the  edges  of  the  tear. 


IT/ethTcL 


Fig.  116. 


Diagonal  Lacerations  of  the  Perineum  (unilateral  and  bilateral),  as  seen  through  separated 
labia  right  after  labor. 

As  the  median  laceration  seldom  extends  beyond  the  external 
sj)hincter,  the  red  color  may  be  absent  from  the  bottom,  but  it  will  be 
replaced  by  the  lighter  bluish  cutaneous  lining  of  the  anus. 

When  a  transverse,  diagonal,  V-shaped  or  irregular  laceration  occurs 
without  an  extension  into  the  skin,  it  may  easily  be  overlooked  by  the 
inexjierienced,  since  the  vulva  apjjears  normal  from  without,  and  the 
bruised  mucous  membrane  at  the  vaginal  entrance  is  often  about  the 
same  in  color  as  the  raw  surfaces.  The  finger  should  be  introduced 
first  to  ascertain  if  sore  places  be  present  and  to  grasp  the  perineal 
body  with  the  help  of  the  thumb  externally.  When  the  finger  gets 
into  a  rent  the  thumb  and  finger  will  notice  the  absence  of  the  normal 
thickness,  and  can  determine  how  much  of  the  perineal  body  is  left 


DIAGNOSIS    OP   PEEINEAL    AND    PELVIC-FLOOE    LACERATIONS.       179 

unruptured.  Sometimes  only  the  skin  will  intervene  between  them. 
When  the  rupture  seems  deep  the  thumb  may  be  introduced  into  the 
rectum  and  then  approximated  to  the  finger  in  the  vagina  and  thus 


Fig.  117. 


JucCbvit-rrf^ 


Slttn 


^■^' 


its' 


'jSh,Tt 


Jhius 


Fig.  117.— Diagonal  Bilateral  Laceration  with  Vulval  Extension  through  Median  Line  Raph6 
as  expanded  for  inspection  after  labor  (Y). 

Fig.  118.— Similar  Laceration  extending  into  Rectum.  (It  is  difficult  to  accurately  represent  a 
laceration  into  the  rectum  on  a  flat  surface,  as  its  contour  varies  with  the  amount  of  separation 
of  the  labia.) 

determine  the  condition  of  the  raphe,  and  the  amount  of  tissue  left 
over  the  anus  and  anterior  rectal  wall. 

Inspection  reveals  an  oval  crescentic  or  irregular  gaping  wound, 
whose  edges  are  often  ragged  and  which  needs  a  thorough  willing 
out  to  be  estimated  (Fig.  116). 

When  a  median  laceration  is  united  with  one  or  two  diagonal  ones 
near  the  fourchette  so  as  to  form  an  incomplete  or  complete  Y,  the 
figure  when  expanded  for  inspection  will  present  the  fusion  of  the 
double  triangle  with  a  half  or  whole  crescent  (Fig.  117).    AVhen  the 


Fig.  119. 


Fig.  120. 


Tourchette 


Jucchtvcnv 


Fig.  119.— Double  Diagonal  and  Transverse  Laceration  combined  (n^),  expanded  for  inspection. 
Fig.  120.— Double  Diagonal  Laceration  with  Vulval  Extension  combined  with  a  Transverse 
one  (^). 

rectum  is  invaded  there  will  be  a  projection  of  anal  skin  and  mucous 
membrane  into  the  external  cutaneous  edge  (Fig.  118),  and  a  more 
extensive  raw  surface  on  either  side. 


180         LACERATION    OF   THE    PERINEUM    AND    PELVIC    FLOOR. 

The  compounding  of  a  V-shaped  and  transverse  laceration  looks 
something  like  the  Y-shape,  but  is  much  further  away  from  the  anus 
(Fig.  119). 

The  conjunction  of  the  transverse  and  Y-shaped  makes  a  star  (Fig. 
120).  White  fibrous  and  muscular  tissue,  sometimes  the  rectal  wall 
and,  if  the  rectum  be  opened,  the  rectal  mucous  membrane  will  be 
seen  at  the  bottom. 

II.  Of  Old  Lacerations. — As.  the  cicatrized  edges  of  lacerated  peri- 
neal tissues  are  not  drawn  up  to  their  former  position,  but  down  into  the 
granulating  surface,  the  cicatrix  holds  them  out  of  place  and  often 
creates  a  vulval  gap  or  opening  filled  with  collapsed  tissues.  The  first 
thing  then  to  seek  for  in  diagnosticating  old  perineal  lesions  is  to 
hunt  out  by  palpation  the  displaced  and  relaxed  parts.  For  informa- 
tion upon  this  point  see  Chapters  I.  and  III. 

Palpations  of  Old  Perineal  Lacerations. 

To  determine  whether  or  no  the  relaxation  or  displacement  be  due 
to  laceration  requires  farther  attention.  When  the  relaxation  is  greater 
on  one  side  than  the  other,  or  the  elevation  corresponding  to  the 
median  line  raphe  (Figs.  67  and  68)  is  felt  drawn  to  one  side,  or  one 
portion  of  the  perineum,  as,  for  instance,  a  levator  vaginse  or  con- 
strictor cunni,  is  flabby  and  the  rest  of  the  perineum  firm,  the  relaxa- 
tion is  probably  due  to  a  laceration. 

When  the  median  line  elevation  or  raphe  is  absent,  or  represented  by 
a  depression  of  hardened  tissues,  and  the  levator  vaginee  and  constrictor 
cunni,  while  relaxed  and  forming  a  large  deep  pubic  fossa  at  each  side, 
do.  not  form  a  depression  on  either  side  of  the  median  line,  there  must 
have  occurred  a  median  laceration. 

When  the  tear  extends  along  one  side  of  the  median  line,  the  peri- 
neal fossa  (See  Examination  of  Perineum,  Chapter  III.)  on  that  side 
will  be  the  better  developed  of  the  two,  and  will  extend  down  or 
through  the  transversus  perinei.  The  edge  of  the  laceration  and  the 
contiguous  median  line  raphe  may  often  be  detected  by  the  experi- 
enced finger  on  the  sound  side  of  the  median  line.  Such  laceration 
deep  enough  to  involve  the  transversus  perinei,  or  its  central  attach- 
ment, leaves  a  wide  depression  of  hardened  tissue  in  the  place  of  the 
fourchette,  which,  if  the  anal  sphincter  be  torn,  leads  back  to  the 
membranous  edge  of  the  anus. 

A  diagonal  laceration  extending  only  through  one  levator  vaginae 
gives  a  deep,  but  not  wide,  pubic  fossa  on  the  same  side.  A  double 
diagonal,  or  V-shaped,  laceration  is  accompanied  by  a  deepening  of 
both  perineal  fossae,  and  sometimes  by  a  raised  central  tongue  or  vagi- 
nal mucous  membrane  which  can  be  felt  behind  the  depressed 
cicatricial  tissue  situated  at  or  behind  the  hymen.  The  Y-shaped  lacer- 
ation is  known  by  the  same  signs  in  addition  to  those  of  a  median 


DIAGNOSIS    BY    RECTAL   PALPATION.  181 

laceration,  viz.,  a  median  line  depression  and  widening  and  lengthen- 
ing of  the  pubic  fossse. 

A  transverse  laceration  usually  produces  a  transverse  depression 
internal  to  the  commissure  or  fourchette  extending  into  the  pubic 
fossa  on  one  or  both  sides.  A  wide  V-shaped  laceration  produces  a 
similar  depression,  but  it  is  felt  to  extend  to  the  bellies  of  the  levatores 
ani  around  the  tongue  of  mucous  membrane  instead  of  into  the 
pubic  fossae.  T-shaped  lacerations  have  a  slight  transverse  depres- 
sion, a  widening  of  the  perineal  fossa  forward,  and  the  longitudinal 
depression  instead  of  elevation  of  the  fourchette  or  commissure.  The 
inverted  T  (jj  has  a  transverse  depression  with  a  normal  fourchette, 
but  has  the  perineal  fossae  deepened  and  widened  backwards  only, 
and  has  a  cicatricial  line  or  depression  that  can  sometimes  be  felt  over 
the  rectum  in  the  median  line,  or  else  allows  the  finger  to  feel  the 
folded  rectum  more  easily  than  natural. 

Stellate,  cross-shaped  and  other  compound  lacerations  may  be  partly 
diagnosticated  by  the  alterations  mentioned  above,  and  partly  by  the 
large  extent  of  firm  cicatricial  tissue  at  their  site. 

Occasionally  we  find  a  lacerated  vulvo-vaginal  outlet  that  is  as  nar- 
row or  narrower,  and  perhaps  firmer  at  the  sides,  than  normal,  so  that 
the  pubic  fossa  is  as  difficult  or  more  difficult  to  detect  as  in  the  virgin, 
yet  the  fourchette  is  gone,  and  its  place  taken  by  the  sagging  urethra 
and  vaginal  walls.  Below  the  narrow  elongated  orifice  upon  the 
shx)rtened  but  firm  perineal  body  is  felt  a  large  firm  scar  with  a  nar- 
row extension  through  the  separated  carunculse  at  or  a  little  to  one 
side  of  the  median  line.  This  condition  is  produced  by  the  contrac- 
tion of  a  large  cicatrix  drawing  the  ends  of  the  torn  muscles  and 
fascia  down  toward  the  posterior  end  of  the  wound  but  not  toward 
the  median  line.  All  of  the  perineal  tissues  may  be  firm,  but  they  do 
not  close  the  vulvo-vaginal  outlet.  The  recto- vaginal  promontory  may 
also  be  flattened  as  far  back  as  the  coccyx. 

-    Diagnosis  by  Rectal  Palliation. 

As  the  perineal  body  in  section  is  triangular  (Figs.  26  to  31),  its  size 
and  form  may  be  quite  accurately  estimated  (without  reference  to  the 
superficial  or  visible  tear)  by  a  finger  in  the  rectum  on  its  rectal  sur- 
face, another  on  the  vulvo-vaginal,  and  the  thumb  on  the  cutaneous 
surface. 

Among  the  most  common  losses  of  substance  in  the  perineum  are 
those  external  to  the  perineal  septum  and  levator  fascia.  They  are 
due  usually  to  median  lacerations  which  shorten  the  cutaneous  side 
of  the  triangle  and  enlarge  the  vulval  angle.  This  shortening  of  the 
external  cutaneous  side  and  enlarging  of  the  angle  goes  on  progres- 
sively with  larger  tears,  until  the  sphincter  ani  occupies  the  whole 


182 


LACERATION    OF    THE   PERINEUM    AND    PELVIC    FLOOR. 


cutaneous  side,  or  until  the  entire  body  is  represented  by  a  fiat  fascial 
or  cicatricial  band  along  the  anterior  rectal  wall,  containing  portions 
of  the  perineal  septum  and  levator  fascia.  Fig.  121  represents  by 
lines  the  parts  of  the  triangle  lost  by  lacerations  of  different  extent. 

Another  common  form  includes  primarily  the  perineal  septum  and 
recto-vaginal  end  of  the  raphe,  viz.,  the  diagonal.  In  the  milder  grade 
there  is  merely  a  shortening  of  the  rectal  side  depressing  the  recto- 
vaginal angle,  as  in  the  single  or  double  diagonal.  In  the  next  grade 
the  raphe  is  destroyed  below  the  constrictor  cunni  attachment  and  the 
triangle  is  cut  almost  or  quite  square  off  as  in  the  deep  Y-shaped  or 
the  T-shaped.  When  there  is  but  little  cicatrization  the  transversus 
perinei  is  easily  reached  on  either  side  by  drawing  the  rectum  to  first 
one  side  and  then  the  other  so  as  to  render  it  tense,  while  the  finger 


Fig.  122. 


Fig.  123. 


Fig.  121.— Degrees  of  Median  Laceration  through  the  Perineal  Raphe  represented  by  curved 
lines  1,2,  3,4.  The  curves  may  be  increased  or  diminished  at  the  ends,  altering  the  superficial 
extent  without  altering  the  depth  or  degree. 

Fig.  122.— Degrees  of  Extension  of  Diagonal  Laceration  through  Perineal  Raphe.  The  lines  1, 
2, 3,  instead  of  leading  from  the  Raphe  into  the  Rectum,  lead  to  one  side  of  it. 

Fig.  123.— Deformity  produced  by  the  Transverse  or  deep  Double  Diagonal  without  forward  ex- 
tension. 


presses  back  along  the  pubic  ramus.  The  next  grade  leaves  only  the 
sphincter  ani.  In  this  form  we  have  colpocele,rectocele  and  cystocele 
unless  sufficient  cicatrization  occurs  to  act  as  a  substitute  for  the 
raphe.  It  is  also  possible  for  the  lacerations  at  the  upper  part  to  go 
entirely  through  the  raphe,  divide  the  perineal  body  in  two,  and  de- 
stroy its  function  without  much  diminishing  its  bulk  or  shape  as  pal- 
pated or  inspected.  Fig.  122  represents  by  lines  the  portions  of  the 
perineal  triangle  destroyed  by  such  lacerations  as  ascertained  by  the 
combined  rectal  palpation.  The  ease  with  which  the  vagina  can  be 
everted  by  the  finger  in  the  rectum,  and  the  thin  membranous  nature 
of  the  tissue  over  the  rectal  finger  are  also  characteristic. 

In  the  transverse  laceration  when  cicatrized  or  only  partly  through 
the  septum,  the  transverse  groove  in  the  base  of  the  triangle  can  be 


DIAGNOSIS   BY    INSPECTION.  183 

easily  felt  and  measured  (Fig.  123).  A  cicatrized  V-shaped  laceration 
with  a  retracted  angle  or  tongue  of  tissue  often  produces  the  same 
depression  in  the  centre. 

When  an  uncicatrized  transverse  laceration  with  rectocele,  or  tend- 
ing to  it,  is  present,  the  absence  of  the  attachment  of  the  levatores 
vaginae  is  known  by  the  attenuation  and  want  of  resistance  of  the 
recto-vaginal  angle  of  the  perineal  triangle  when  caught  between  the 
rectal  and  vaginal  finger,  and  by  the  ease  with  which  the  base  or  vul- 
val side  of  the  triangle  or  body  can  be  swung  or  pulled  outward  under 
the  pubic  arch.  By  penetrating  deeper  into  both  vagina  and  rectum, 
the  levator  vaginse  at  the  top  of  the  rectocele  can  be  caught  between 
the  fingers,  and  its  length  and  resistance  estimated  by  dragging  it  for- 
ward and  from  side  to  side  and  putting  its  pubic  ends  upon  the 
stretch,  so  as  to  render  them  distinctly  palpable. 

When  a  laceration  extends  beside  the  raphe  the  extent  of  tissue 
involved  may  be  determined  the  same  as  if  it  were  through  the  raphe. 

The  strength  of  the  perineum  as  a  whole  may  be  tested  by  ajoproxi- 
mating  the  vaginal  and  rectal  finger  at  the  recto-vaginal  promontory 
and  pulling  them  together  in  various  directions,  forward,  backward, 
downward,  from  side  to  side,  etc.  We  thus  often  find  a  small  remnant 
of  the  perineal  body  quite  firm  and  effective  as  a  support. 

Diagnosis  by  Inspection. 

Inspection  alone  gives  a  less  complete  idea  of  the  amount  of  perineum 
or  pelvic  floor  injury  than  palpation.  It  however  reveals  the  position, 
shape  and  extent  of  the  cicatrix,  and  the  amount  of  destruction, 
separation  or  distortion  of  the  superficial  landmarks. 

If  the  caruncles  be  continuous  around  the  vaginal  entrance,  without 
an  intervening  scar,  the  laceration  has  not  involved  the  vaginal  orifices 
or  levator  vaginse  to  any  considerable  extent.  If  they  be  small  and 
all  or  nearly  all  of  them  widely  separated  from  each  other  around  a 
gaping  orifice  that  presents  no  scar  tissue,  there  has  been  probably 
submucous  diffuse  laceration.  If  the  cutaneous  median  line  raphe 
extend  up  above  the  junction  of  the  labia  majora,  the  external  perineum 
is  not  much  affected.  If  the  labia  majora,  however,  pass  straight 
downward  and  backward  and  do  not  converge  to  form  a  posterior  com- 
missure, we  know  that  there  has  been  a  median  laceration.  If  the 
urethra  and  anterior  vaginal  wall  sag  down  into  the  vulva,  or  the 
posterior  vaginal  wall  project,  we  know  that  the  parts  about  the  in- 
troitus  have  been  injured  and  imperfectly  repaired,  whether  the  vulva 
be  firm  and  gaping  or  flabby  and  collapsed.  If  the  perineum  present 
the  ordinary  landmarks  but  sags  downward  so  as  to  project  farther 
than  natural  from  the  pubo-coccygeal  line,  or  conjugate  of  the  outlet, 
a  general  relaxation,  diffuse  submucous  laceration,  or  transverse 
laceration  may  be  inferred. 


184         LACERATION    OF   THE    PERINEUM    AND    PELVIC    FLOOR. 

As  the  labia  are  separated,  evidences  of  a  deep  lesion  will  be  in- 
dicated by  the  altered  appearance  of  the  deeper  pstvis.  If  no  signs  of 
any  tear  be  present,  the  sight  may  not  be  able  to  distinguish  between 
the  simple  relaxation  from  the  pressure  of  displaced  organs  that  is  not 
necessarily  a  result  of  parturition,  and  the  diffuse  submucous  and 
uncicatrized  lacerations  due  to  labor, 

A  unilateral  or  localized  relaxation  greater  than  that  of  the  remain- 
ing parts,  a  participation  of  muscles  distant  from  the  vaginal  orifice 
(as  the  sphincter  ani),a  greater  relaxation  or  softness  of  the  perineum 
than  that  due  to  the  amount  of  pressure  of  the  displaced  organs,  and 
a  want  of  retractability  when  these  organs  are  sujiported,  indicate  the 
lacerated  condition.  Either  a  decided  eversion  or  turning  under  of 
rugate  mucous  membrane  at  an  edge  of  the  scar,  especial!}^  if  the  scar 
be  angular,  curved  or  unilateral,  indicates  a  flap  laceration. 

Combined  Palpation  and  Inspection. 

Having  determined  by  palpation  what  portions  of  the  perineum  are 
relaxed  and  out  of  place,  and  by  inspection  the  superficial  variations, 
we  may  by  combining  paljjation  and  inspection  find  the  relations  of 
the  cicatrices  and  superficial  lesions  to  the  relaxed  or  separated  deeper 
structures. 

By  everting  the  vagina  by  the  finger  in  the  rectum  not  only  can 
the  thickness  and  resisting  power  of  the  perineal  body  be  estimated, 
but  the  cicatrices,  stretched  over  the  anal  finger,  appear  blanched  in 
the  softer  tissues  beside  them  and  can  be  traced  to  their  minute  ends. 
Hidden  lesions  may  thus  become  plainly  visible.  Rectal  eversion  of 
the  vaginal  walls  also  informs  us  how  high  above  the  sphincter  ani 
the  perineal  body  supports  the  rectum,  and  of  the  extent  of  loss  of  the 
raphe  above. 

Diagnosis  of  Old  Lacerations  Extending  into  the  Rectum. 

The  history  of  fecal  incontinence  usually  makes  the  diagnosis  of 
laceration  into  the  rectum  an  easy  one.  Upon  palpation  the  rectal  and 
vaginal  outlets  will  be  found  to  be  in  common.  The  perineal  body 
will  be  completely  divided  and  allow  the  finger  to  glide  back  along 
the  pubic  rami  to  the  anus.  At  the  upper  and  inner  end  of  the  lacera- 
tion the  thin  curved  edge  of  the  recto- vaginal  septum  will  be  felt  about 
the  median  line  ;  or  there  may  be  a  deep  extension  on  one  side,  and  a 
shallow  one  on  the  other,  with  a  median  projecting  tongue  of  recto- 
vaginal septum  between  them.  Inspection  will  reveal  the  red  rectal 
mucous  membrane  posteriorly. 

Diagnosis  of  Lacerations  of  the  Pelvic  Floor. 

1.  Of  the  Anterior  Edge. — Lacerations  of  the  anterior  edge  of  the  levator 
ani  are  accompanied  by  a  relaxed  levator  vaginte  and  widening  of  the 


DEEPER  PORTIONS  OF  THE  PELVIC  FLOOR.         185 

urethral  notches,  the  more  so  on  the  side  lacerated.  The  finger,  in- 
stead of  feeling  the  pubic  attachment  of  the  muscle  near  the  internal 
edge  of  the  pubic  ramus,  traces  it  upon  the  posterior  surface  of  the 
bone  and  farther  from  the  median  line.  The  rectum  at  the  recto- 
vaginal promontory  is  scarcely  as  prominent  as  normal  and  is  flabbier, 
and  makes  a  gentler  backward  curve,  but  it  is  more  easily  palpated 
through  the  relaxed  tissues. 

II.  OJ  the  Levator  Ani  Proper. — When  a  large  part  of  the  levator  ani 
proper  is  lacerated,  the  vaginal  outlet  is  large  and  flabby,  the  recto- 
vaginal promontory  thrown  further  back  from  the  pubic  arch  toward 
the  anus,  and  the  most  prominent  part  further  in  towards  the  coccyx. 
In  lacerations  involving  the  whole  anterior  section,  or  levator  ani 
proper,  the  lower  rectal  curve  (Fig.  31)  is  long  and  low  instead  of  high 
and  short,  as  it  normally  feels  in  the  dorsal  position.  The  urethral 
fossae  are  wide,  and  their  lateral  borders,  usually  formed  by  the  levatores 
ani,  feel  soft  and  receding  instead  of  hard  and  resistant.  The  rectal 
promontory  and  anterior  edge  of  the  levator  ani  are  soft,  flat  and  unusu- 
ally depressible  and  indefinite  to  the  touch  as  far  back  as  the  coccyx. 
The  rectal  promontory  as  felt  per  rectum  is  almost  or  entirely  absent. 
The  posterior  vaginal  sulci  or  grooves  are  wide  and  often  deep  beside 
the  flabby  recto-vaginal  promontory.  The  power  of  lifting  this  por- 
tion of  the  pelvic  floor  at  will  (by  an  effort  to  draw  in  or  contract  the 
anus)  is  diminished  according  to  the  amount  of  laceration.  Finally, 
the  most  striking  peculiarity  in  extreme  cases  is  the  pronounced  pro- 
jection of  the  ordinarily  buried  tip  of  the  coccyx,  and  of  the  ridge  of 
levator  coccygei  fibres  extending  from  the  posterior  surface  of  the  an- 
terior pelvic  wall  near  the  anterior  end  of  the  white  line  on  either  side,, 
to  the  coccyx,  and  forming  by  their  junction  an  angle  or  inverted  Y 
(  ^  ).  (See  Palpation  of  the  Levator  Ani,  Chapter  III.)  Thus  a  very- 
pronounced  false  promontory  is  found  deep  in  the  pelvis.  If  the  patient 
is  put  in  an  uncomfortable  position  or  requested  to  draw  in  the  anus 
so  as  to  hold  back  the  faeces,  this  ridge  will  become  hard  if  not  already 
so.  If  the  laceration  be  unilateral  the  rectum  and  ano-coccygeal 
ligament  will  be  drawn  slightly  toward  the  sound  side.  Such  a  com- 
plete relaxation  of  the  levator  ani  proper  is  occasionally  found  without 
a  tearing  open  of  the  rectum,  and  nearly  always  when  the  rectum  is 
deeply  lacerated.  This  condition  was  found  four  times  in  the  series 
of  cases  already  cited  in  this  chapter,  beside  the  case  in  which  the 
rectum  was  lacerated.  A  failure  to  diagnosticate  this  kind  of  lacera- 
tion would  be  to  fail  in  either  understanding  the  symptoms  or  curing 
the  patient. 

Deeper  Portions  of  the  Pelvic  Floor, 

A  generalized  diffuse  laceration  (so-called  overdistension)  is  known 
by  the  relaxation.  (See  Palpation  of  the  Pelvic  Floor,  Chapter  III.) 
Relaxation  from  laceration  is  usually  unilateral  or  locahzed..    Lacera- 


186         LACEPvATIOX    OF    THE    PERIXEUM    AXD    PELVIC    FLOOR. 

tion  extending  back  into  the  levator  coccygei  fibres  diminishes  the 
size  of  tlie  ridge  on  the  lacerated  side,  or  may  place  the  anterior  edge 
of  the  ridge  back  in  the  posterior  section  of  the  levator  ani. 

If  both  sides  of  the  muscle  are  torn  to  the  same  extent,  the  ridge 
will  be  less  prominent,  and  displaced  higher  up  and  farther  back  on 
both  sides.  If  the  levator  coccygei  fibres  be  lacerated  without  par- 
ticipation of  the  anterior  fibres  of  the  levator  ani,  the  vaginal  entrance 
will  be  normal,  but  the  recto-vaginal  promontory  will  be  high  in  front, 
but  fall  away  more  abruptly  backward,  and  thus  be  narrow  antero- 
posteriorly.  The  tip  of  the  coccyx  will  not  be  as  readily  felt  from  the 
vagina  as  when  the  anterior  muscles  are  lacerated.  Unilateral  lacera- 
tion of  this  portion  alone  increases  the  size  of  the  depression,  or  de- 
pressible  area,  corresponding  to  the  obturato-coccygeus  muscle,  as 
compared  with  the  sound  side.   The  softened  area  is  increased  forward. 

Lacerations  of  the  obturato-coccygeus  are  nearly  always  unilateral, 
and  are  characterized  by  unusual  softness  of  the  fibres  on  one  side, 
or  an  unusual  prominence  of  the  anterior  edge  of  the  coccygeus 
behind.  If  the  tear  extend  into  the  coccygeus  the  greater  sacro-sciatic 
ligament  will  be  unusually  high  and  prominent.  Possibly  a  line  of 
laceration  or  separation  may  be  occasionally  found.  I  have  never 
found  such,  although  I  have  in  a  few  instances  found  the  relaxed 
condition.  A  loosening  or  laceration  of  the  fascia  about  the  white 
line  is  known  by  the  greater  amount  of  curvature  produced  in  it 
during  voluntary  contraction  on  one  side.  Sometimes  a  finger  can 
be  hooked  into  the  curve,  and  almost  get  under  its  edge. 

In  seeking  for  laceration  in  a  relaxed  muscle  we  must  take  the  fact 
into  consideration  that  extensive  lacerations  may,  by  removing  fascial 
support,  relax  the  whole  pelvic  floor.  Voluntary  contraction  will 
often  show  which  muscles  are  torn,  and  which  merely  relaxed.  The 
first  do  not  contract,  the  latter  may. 

Unasual  roominess  of  the  upper  vagina,  with  softness  of  the  deeper 
pelvic  floor  musculature,  unusual  mobility  of  the  cervix  in  a  forward 
direction,  a  low  position  of  the  uterus,  and  a  marked  tendency  of  the 
abdominal  walls  above  the  pubes  to  sink  back  toward  the  promontory 
of  the  sacrum  when  the  dorsal  position  is  assumed,  are  general  signs 
of  relaxation  of  the  pelvic  floor  from  extensive  injury. 

Method  of  Diagnosis. 

The  finger  should  be  so  educated  as  to  be  able  to  recognize  in  a 
general  way  the  presence  and  location  of  pelvic  floor  and  perineal 
lacerations  at  the  first  touch.  In  passing  into  the  genitals  it  should 
notice  the  amount  and  shape  of  the  tissues  at  the  fourchette,  the  con- 
dition of  the  hymen  or  caruncles,  the  depth  and  size  of  the  pubic 
iossse,  the  size  and  shape  of  the  urethral  and  rectal  notches  and  vag- 
inal grooves  or  sulci,  the  height  and  width  antero-posteriorly  of  the 


PREYENTIOX  OF  LACERATIONS.  187 

recto-vaginal  promontory,  and  the  absence  or  presence  of  an  elevation 
of  the  tip  of  the  coccyx  and  levator  coccygei  fibres.  If  we  find  the 
last-mentioned  structures  prominent,  and  the  promontory  flat,  we 
look  for  a  lacerated  levator  ani.  If  these  parts  are  normal,  but  the 
parts  below  them  relaxed,  or  otherwise  altered  in  shape  or  relation- 
ship, they  should  be  more  carefully  examined,  after  the  usual  intra- 
pelvic  examination  has  been  made.  It  is  well  in  all  cases  of  multipara 
with  a  relaxed  posterior  vaginal  wall  to  touch  all  of  the  principal 
landmarks  of  the  pelvic  floor  in  rapid  succession,  as  it  takes  but  a 
moment.     (See  Palpation  of  Pelvic  Floor,  Chapter  III.) 

Prognosis. 

The  chances  for  a  complete  ideal  cure  are  favorable  only  by  the 
immediate  operation.  After  the  time  for  that  has  passed,  the  shorter 
the  delay  after  inflammation  and  suppuration  have  subsided,  the 
better  the  opportunity  for  restoring  the  parts  as  they  were  before. 
The  longer  the  separated  parts  are  left  to  degenerate  from  loss  of  func- 
tion, and  the  longer  the  support  to  the  inferior  portion  of  the  pelvic 
connective  tissues  remains  impaired,  the  less  chance  is  there  to  secure 
a  normal  coaptation  of  the  parts  that  belong  together,  or  to  secure 
perfect  union  after  such  coaptation,  or  to  relieve  the  effects  of  the  long- 
continued  laceration  upon  the  surrounding  tissue.  Indeed,  the  re- 
sulting changes  due  to  the  laceration  may  finally  become  permanent, 
and  be  but  little  or  very  slowly  benefited  by  perineorrhaphy. 

Prevention  of  Lacerations. 

The  prevention  of  perineal  and  pelvic-floor  lacerations  should  be 
studied  in  the  works  on  obstetrics.  Yet  from  the  standpoint  of  the 
gynecologist,  who  is  chiefly  concerned  with  cases  in  which  injury  of  the 
parts  is  pretty  sure  to  result,  it  is  well  to  give  the  matter  a  little  farther 
consideration.  The  first  thing  to  be  thought  of  in  such  cases  is  to  so 
manage  the  perineum  and  pelvic  floor  that  they  will,  if  lacerated,  be 
in  a  condition  for  immediate  successful  repair,  or  an  ultimate  restora- 
tion of  function. 

The  management  of  the  deeper  pelvic-floor  muscles  consists  mainly 
in  securing  a  passage  of  the  presenting  part  slow  enough  to  allow  of 
the  requisite  dilatation.  Nature's  way  of  doing  this  is  by  persistence 
of  the  bag  of  waters  until  they  burst  at  the  vulva.  To  imitate  this 
natural  mechanism  the  accoucheur  has  but  to  let  things  alone,  and 
assist  his  patient  to  take  things  as  easily  and  calmly  as  possible.  The 
advice  given  by  teachers  and  text-books  to  diagnose  by  palpating  the 
fontanelles  is  harmful  in  its  influence,  and  leads  younger  practitioners 
to  spend  a  large  part  of  the  time  of  their  attendance  upon  the  confine- 
ment in  pokhig  the  finger  about  in  utero,  bruising  the  cervix,  and 
destroying  the  resisting  power  of  the  membranes. 


188         LACEEATION    OF    THE    PERTXEUM    AND    PELVIC    FLOOR. 

The  next  important  service  of  the  membranes  is  to  prevent  that 
superficial  bruising  and  ecchymosis  about  the  vaginal  entrance  which 
often  lead  to  the  deeply  penetrating  lacerations,  and  also  the  so-called 
inevitable  one.  Another  is  to  provide  the  wedge  to  prepare  the  vulval 
and  vaginal  rings  for  the  head. 

AVhen  the  membranes  do  not  persist  long  enough,  a  slow  advance 
gives  time  for  the  formation  of  a  caput  succedaneum,  which  will  act 
as  a  wedge  in  the  vaginal  and  vulval  outlets  (Dumas)  in  place  of  the 
membranes.  A  rapid  advance  over  the  deeper  parts  leaves  the  caput 
succedaneum  to  be  formed  after,  instead  of  before,  the  whole  perineum 
is  pressed  upon  and  bruised,  and  thus  often  too  late  to  prevent  the 
laceration. 

When  the  normal  method  of  dilatation  of  the  pelvic  floor  and 
perineum  does  not  occur,  the  assistance  of  the  accoucheur  must  sup- 
ply the  wedge,  the  restraining  force,  and  the  directing  force.  The 
latter  is  lost  when  the  perineum  is  not  normally  folded  at  the  four- 
chette,  so  as  to  give  the  ;groper  slope  to  the  pelvic  floor  (Figs.  Ill  and 
124).  As  we  work  for  a  vigorous  condition  of  the  parts  after  labor,  we 
should  not  supply  this  force  by  pressing  upon  the  perineum  in  front  of 
the  anus,  nor  by  fingering  the  delicate  rectal  walls,  but  should  choose 
the  post-anal  cutaneous  surface  for  pressure,  as  was  taught  by  Ritgen. 
If  the  head  needs  also  to  be  temporarily  retarded,  the  finger  of  the 
unemployed  hand  may  be  passed  into  the  vulval  or  vaginal  entrance 
instead  of  being  placed  against  the  perineal  body.  If  the  perineum 
be  not  too  rigid  the  fourchette  and  posterior  commissure  may  be 
digitally  drawn  back  toward  the  anus  at  the  beginning  of  the  pain, 
and  the  raphe  be  held  back  until,  but  only  until,  the  head  advances 
upon  it.  This  is  necessary  where  there  is  a  tendency  to  a  wide  sepa- 
ration of  the  vulval  and  vaginal  rings  (Fig.  112)  threatening  a  diastasis 
of  the  muscles,  or  a  transverse  perineal  laceration.  Should,  however, 
too  much  be  attempted  in  the  way  of  digital  dilatation,  the  perineum 
will  be  bruised,  and  the  condition  we  are  so  anxious  to  prevent  will 
be  produced. 

Rather  than  delay  the  head  after  it  be  determined  that  laceration 
must  eventually  occur,  we  should  deliver  it  before  too  much  bruising 
has  taken  place,  thus  precipitating  the  laceration  at  a  time  when  its 
immediate  repair  can  be  successfully  accomplished.  But  as  a  lacera- 
tion heals  less  perfectly  by  first  intention  than  a  well-chosen  incision, 
it  may  sometimes  be  better  to,  perform  colpotomy,  episiotomy  or 
perineal  tenotomy. 

Perineal  •  Incisions. 

In  imitation  of  nature's  method  of  relaxing  the  perineum  by  a 
laceration  through  the  smallest  of  the  perineal  rings  (the  obstructing 
one),  it  has  been  proposed  to  make  an  incision  through  the  internal 


COLPOTOM  Y — EPISIOTOM  Y.  189 

perineal  ring  or  levator  vaginse  (colpotomy)  or  the  external  perineal 
ring  or  constrictor  cunni  (episiotomy),  according  as  one  or  the  other 
fails  to  exhibit  the  requisite  distensibility  for  the  passage  of  the  head. 
Considerable  judgment  must  be  used  in  performing  either  of  these 
operations,  for  from  the  moment  the  incision  is  made  a  weak  point  is 
created  which  will  lacerate  deeply  under  strong  pressure.  But  little 
more  stretching  can  then  be  expected,  and  the  dilatation  of  the  orifice 
will  be  in  proportion  to  the  depth  of  the  incision.  Therefore,  if  the 
ring  be  not  already  dilated  almost  to  the  required  extent,  the  incision 
will  be  inadequate,  and  will  be  enlarged  by  tearing,  and  may  even 
extend  into  the  rectum.  The  only  laceration  into  the  rectum  of  the 
series  reported  in  these  pages  occurred  after  an  incision  in  the 
perineum.*  On  the  other  hand,  if  we  wait  too  long  the  parts  may 
become  too  much  bruised  for  primary  union.  Hence  the  proper  time 
is  as  soon  as  the  ring  has  ceased  to  enlarge — or  enlarges  so  slowly  that 
but  little  more  dilatation  can  be  expected — and  before  complete  dry- 
ness and  numbness  of  the  vaginal  entrance  has  occurred. 

Colpotomy. 

The  place  for  the  incision  is  at  one  side  of  the  median  line,  and  the 
greater  the  amount  of  dilatation  required  the  farther  to  the  side  should 
be  the  incision.  Its  direction  should  be  diagonal,  extending  forwards 
towards  the  median  line  intersection  of  the  external  or  constrictor 
cunni  ring,  or  fourchette.  When  one  incision  does  not  afford  the  re- 
quisite amount  of  dilatation,  another  on  the  opposite  side  may  be 
made.  By  rectal  indagation  between  or  just  after  pains  we  may  ascer- 
tain by  the  direction  of  the  raphe,  which  is  easily  recognized  on  the 
anterior  rectal  wall,  the  side  that  is  stretched  the  most  and  make  an 
incision  accordingly.  I  prefer  to  cut  first  on  the  least  dilated  side,  as 
that  part  is  the  less  bruised  and  will  have  less  traction  upon  it  when 
united  subsequently. 

A  straight  blunt-pointed  bistoury  is  the  best  instrument  for  the 
operation,  although  a  pocket-knife  may  be  used.  Just  as  a  pain  is 
subsiding  the  left  index  finger  should,  as  soon  as  it  can  find  room,  be 
slipped  between  the  ring  and  the  head,  and  the  incision  made  with 
the  other  hand  into  the  edge  of  the  ring  as  held  tense  by  the  head  and 
finger.  Care  should  be  taken  not  to  extend  the  incision  along  the  su- 
perficies any  farther  than  necessary,  as  such  extension  would  increase 
the  size  of  the  wound  without  aiding  in  the  dilatation. 

Episiotomy. 

When  the  constrictor  cunni  is  the  unyielding  part  of  the  perineum, 
or  when  the  levator  vaginae  and  hymen  have  been  so  slow  in  dilating 

*  Patient's  testimony. 


190         LACEEATION    OF    THE    PERINEUM    AND    PELVIC    FLOOR. 

that  any  further  bruismg  must  destroy  the  elasticity  of  the  parts, 
episiotomy  may  be  performed.  It  is  done  at  one  side  of  the  median 
line,  but  not  so  far  to  one  side  as  colpotomy.  The  incision  or  incisions 
are  also  less  diagonal,  and  extend  or  converge  toward  the  posterior 
commissure  of  the  labia  majora.  Care  must  be  taken  not  to  incise  the 
labial  ring,  for  the  skin,  if  given  time,  will  almost  always  stretch 
sufficiently. 

Perineal  Tenotomy. 

When  the  dilatation  has  reached  such  a  degree  that  one  incision  will 
afford  all  of  the  dilatation  needful,  then  perineal  tenotomy,  or  an  in- 
cision into  the  median  line  raphe  or  tendon,  is  preferable.  According 
to  the  place  and  amount  of  such  incision  the  superficial,  the  deep  or 
the  whole  perineal  tissues  (muscles,  fasciae  and  superficies)  can  be  re- 
laxed.    The  disadvantage  of  perineal  tenotomy  is  that  it  cannot  be 


'pOStirlor  vaffinaL 
Wall .  , 


Incisions  to  be  made  in  Perineal  Tenotomy.— Compare  with  Figs.  32  and  111. 
Cv  anterior  edge  of  constrictor  cunni  ffoureliette) ;  I,  anterior  edge  of  levator  vaginse  ;  ac,  depth 
of  large  incision,  and  course  of  tenotome  in  the  subcutaneous  incision  ;  da,  incision  for  relaxing 
levator  vaginae  et  ani ;  6  c,  incision  for  relaxing  constrictor  cunni  and  slightly  the  levator  vaginae. 

made  to  relax  any  one  ring  quite  as  much  as  the  other  operations. 
Its  chief  advantages  are  that  with  a  moderate  incision  it  can  be  made 
to  relax  the  whole  perineum  better,  and  that  the  stitches  draw  together 
the  whole  perineum  more  nearly  as  it  was  before. 

The  operation  may  be  performed  very  much  as  is  colpotomy  Qd.  189), 
except  that  the  incision  must  be  made  in  the  median  line.  If  the 
vaginal  or  internal  perineal  ring  be  the  part  chiefly  at  fault,  the  inci- 
sion is  mostly  vaginal  and  should  penetrate  into  the  tissues  until  an 
appreciable  relaxation  is  produced ;  if  the  vulval  rings  be  the  offending 
ones,  the  incision  should  be  mainly  in  the  vulva;  if  the  whole  peri- 
neum be  rigid,  the  incision  should  be  through  both.  Fig.  124- shows 
by  curved  lines  the  place  and  extent  of  the  incisions.  The  interrupted 
lines  show  the  extent  of  the  fmaller  incisions.  In  order  to  avoid 
wounding  the  rectum,  its  course  should  be  determined  by  rectal  inda- 
gation. 

When  the  conditions  are  favorable  the  tenotomy  should  be  performed 


PERINEAL   TENOTOMY 


191 


subcutaneously  and  antiseptically.  At  the  subsidence  of  a  pain  the 
rings  are  held  b}^  the  index  placed  at  one  side  of  the  median  line,  and 
if  necessary  the  middle  finger  at  the  other.  A  very  narrow  tenotome 
should  be  used  whose  blade  or  cutting  portion  is  no  more  than  a  half 
inch  in  length  (Fig.  125).  For  relaxation  of  the  whole  perineum  the 
blade  should  be  entered  flat  (with  cutting  edge  turned  to  one  side)  just 
external  to  the  ring  of  the  constrictor  cunni  (Fig.  124,  c).  The  blade 
point  should  pass  straight  down  almost  parallel  Avith  the  posterior 
vaginal  wall,  or  deviating  slightly  toward  it,  for  half  an  inch.  Then  the 
cutting  edge  is  turned  backward  toward  the  vaginal  wall  and  the  point 
carried  to  a  point  in  the  vaginal  wall  opposite  to,  or  back  of,  the  ring 
of  the  levator  vaginae  (6  or  a)  according  as  much  or  little  effect  upon 
the  internal  perineal  ring  (I)  is  desired.  When  the  vaginal  finger 
placed  over  the  vaginal 'portion  of  the  raphe  feels  the  point  of  the  in- 
strument under  the  mucous  membrane,  the  knife  is  thrust  no  farther 
but  is  made  to  cut  upward  through  the  raphe  at  the  same  time  that 
it  is  being  withdrawn.  If,  however,  the  point  of  the  knife  makes  an 
appreciable  wound  through  the  vaginal  mucous  membrane,  the  re- 

FlG.  125. 


Perineal  Tenotome. 


mainder  of  the  incision  should  be  out  through  the  mucous  membrane 
and  vulval  skin,  so  as  to  make  an  open  wound  of  it.  If  the  constrictor 
cunni  be  dilatable,  the  tenotome  should  be  entered  internal  to  the 
muscle  (at  d).  The  knife  enters  along  the  curved  lines  representing 
the  bottom  of  the  incisions  in  Fig.  124,  and  makes  about  the  same-sized 
wound  as  in  the  other  method,  but  the  cutting  is  upward  instead  of 
downward.  The  knife  may  in  some  cases  be  passed  the  required  depth 
under  the  vulval  skin  and  mucous  membrane  and  the  cutting  be  made 
just  toward  instead  of  from  the  joerineal  centre.  We  can  then  stop  as 
soon  as  we  feel  the  desired  amount  of  relaxation  to  have  occurred.  It 
is  also  possible,  by  introducing  the  knife  nearer  the  posterior  commis- 
sure or  labial  ring  and  giving  it  a  direction  parallel  with  the  skin,  to 
divide  the  perineal  centre,  or  attachments  of  the  transverse  perinei 
above  the  sphincter  ani — but  such  is  seldom  necessary. 

Just  before  operating  the  parts  should  be  well  cleansed,  and  the- 
knife  and  fingers,  after  also  being  cleansed,  dipped  in  a  five  per  cent, 
aqueous,  or  ten  per  cent,  oleaginous,  solution  of  carbolic  acid,  or  their 
equivalent.     Immediately  after  operating  the  parts  should  be  kept 


192         LACERATION    OF    THE    PERHsTEUM    AND    PELVIC    FLOOR. 

compressed  between  the  thumb  and  fingers,  to  prevent  hemorrhage, 
and  two  or  three  applications  of  collodion  be  made  to  close  the  opening. 
As  soon  as  the  head  advances  the  fingers  may  be  taken  out  of  the 
vagina,  and  the  parts  pressed  against  the  head.  Should  the  head 
recede  too  much  between  pains  to  allow  of  such  pressure,  it  can  be 
held  down  against  the  perineum  by  the  fingers  placed  in  front  of  the 
coccyx.  An  aneesthetic,  local  or  general,  will  oftener  be  required  in  this 
last  operation  than  in  the  others,  which  are  less  delicate. 

Delivery  after  Perineal  Incisions. 

After  the  perineum  has  been  incised  it  must  of  course  be  carefully 
managed.  The  directing  and  restraining  forces  must  be  supplied  by 
the  accoucheur,  and  the  head  slowly  and  carefully  delivered  between 
pains.  An  anaesthetic  should  be  given  to  the  extent  of  suppressing 
voluntary  efforts,  unless  the  co-operation  of  the  patient  can  be  obtained. 

Choice  of  Methods. 

When  the  levator  vaginse  cannot  be  safely  dilated  to  form  a  ring 
three  inches  in  diameter,  bilateral  colpotomy  should  have  preference 
over  the  other  incisions,  since  a  median  incision  of  moderate  size  could 
scarcely  afford  the  requisite  amount  of  dilatation.  When  the  diameter 
of  the  ring  reaches  three  inches  and  the  head  has  rotated  almost  or 
quite  to  the  median  line,  a  median  incision  or  tenotomy  is  the  prefer- 
able jDrocedure.  This  last  incision  should  extend  through  the  ring  of 
the  constrictor  cunni  in  case  that  muscle  is  also  undilated.  \Vlien  in 
addition  to  the  bilateral  colpotomy  the  constrictor  cunni  also  needs 
relaxing,  the  diagonal  incisions  may  be  made  to  meet  at  the  ring  of 
that  muscle,  and  be  extended  slightly  downward  through  the  raph6, 
thus  completing  the  Y.  Or,  when  the  ring  of  the  levator  vaginae  is 
three  inches  and  that  of  the  constrictor  cunni  requires  a  slight  incision, 
the  diagonal  single  incision  may  take  a  direction  toward  the  posterior 
commissure  and  pass  through  both  rings.  Thus  the  two  operations 
are  performed  by  a  single  cut  (colpo-episiotomy).  This  does  not 
prevent  us  from  making  another  diagonal  incision  on  the  other  side, 
and  is  the  operation  most  usually  performed  under  the  name  epis- 
iotomy. 

When  the  levator  vaginae  is  almost  or  quite  dilated  or  dilatable,  and 
the  constrictor  cunni  is  entirely  at  fault,  the  best  method  is  to  incise  the 
raphfe,  and  if  the  levator  vaginae  be  then  found  to  afford  resistance,  to 
extend  the  cut  backward.  A  rigidity  of  the  external  muscle  precluding 
a  safe  dilatation  to  a  diameter  of  three  inclics  would  make  it  necessary 
to  extend  the  median  incision  to  the  perineal  centre  (at  the  meeting 
of  the  transverse  perinei)  and  would  call  for  a  bilateral  episiotomy. 


TEEATMENT   BY   COAPTATIOlSr.  193 

After  Management. 

Incisions  passing  deep  into  the  raph6,  or  more  than  half  way  through 
the  belly  of  a  muscle  should  be  united  soon  after  the  labor  is  completed. 
Slight  subcutaneous  incisions  in  the  raphe  may  be  left  alone;  deep  ones 
should  be  sewed  up  along  the  line  of  incisions  by  deep  stitches.  One  or 
two  vulvo- vaginal  and  possibly  a  cutaneous  stitch  will  be  needed.  Silk- 
worm gut  taken  directly  out  of  a  five  per  cent,  solution  of  carbolic  acid, 
and  introduced  with  aseptic  precautions,  is  preferable  as  being  noncon- 
ductive  of  germs,  and  subsequently  unirritating.  It  may  be  removed 
on  the  fourth  or  fifth  day.  The  puncture  made  by  the  tenotome  is  to 
be  kept  closed  by  a  stitch  or  covered  by  the  flexible  collodion. 

Treatment  of  Perineal  Lacerations. 

Immediately  after  labor  a  laceration  may  be  united  by  sutures, 
by  coaptation,  or  treated  as  an  open  wound.  After  the  wound  has 
healed  without  restoring  a  satisfactory  condition  of  the  parts,  the  only 
treatment  left  is  by  support  or  by  secondary  perineorrhaphy. 

Superficial  Lesions. 

Wounds  that  do  not  extend  into  the  muscles  or  raphe  should  be 
treated  upon  the  same  principles  as  open  wounds  upon  any  other 
part  of  the  body. 

Treatment  by  Coaptation. 

The  great  majority  of  gynecologists  of  to-day  advise  the  suturing 
of  extensive  perineal  lacerations  after  labor;  yet  there  are  some  of  the 
best  authorities,  such  as  Fordyce  Barker  and  Charpentier,  who  advise 
against  operative  measures. 

Charpentier^  washes  off"  the  wounded  surfaces,  carefully  places  them 
in  accurate  coaptation,  ties  the  thighs  together  and  then  keeps  the 
patient  on  the  back.  A  compress  dipped  in  a  one  per  cent,  solution 
of  carbolic  acid  is  kept  against  the  perineum,  and  the  parts  gently  irri- 
gated with  the  same  solution  four  times  in  the  twenty-four  hovirs,  and 
also  after  urinating.  The  bowels  are  controlled  by  opiates  until  the 
fourth  day,  when  a  dose  of  oil  is  administered.  At  the  end  of  forty- 
eight  hours  the  patient  is  placed  for  the  first  time  on  her  side  and  the 
edges  of  the  wound  examined.  He  has  always  found  union  by  first 
intention  in  the  posterior  part  of  the  cutaneous  wound,  followed  by  a 
rapid  closure  of  the  remainder.  After,  the  examination  the  thighs  are 
again  tied  together  by  a  ribbon. 

As  the  posterior  part  of  the  tear,  viewed  externally,  is  often  only  through  the  skin 
and  fat ;  as  this  is  the  only  place  where  Charpentier  clainas  to  get  union  by  first  inten- 
tion ;  as  no  mention  is  made  of  the  parts  in   the  vaginal  entrance  whose  restoration 

*  Traitd  des  Accouchements. 
13 


194        LACERATIOX    OF    THE    PERIXEr^I   AXD    PELVIC    FLOOR. 

is  of  the  greatest  value  ;  and  as  he  seems  to  regard  a  cicatrized  perineum  all  that  is  to 
be  desired,  it  is  impossible  to  consider  his  success  so  satisfactory  that  all  attempt  at 
anything  better  should  be  abandoned. 

Immediate  Perineorrhaphy. 

The  following  personal  observations  have  long  since  led  nie  to  regard 
the  imraediate  repair  of  extensive  perineal  lacerations  hy  suture  not 
only  a  benefit  but  a  necessity  to  the  parturient  woman.  (1)  When 
the  laceration  is  sutured,  union  by  first  intention  occurs  as  far  forward 
as  the  front  stitch  and  no  farther  (^thus  proving  the  action  of  the  stitch) ; 
the  resulting  perineum  is  as  large  and  complete  in  most  cases  as  that  in 
the  nullipar;  even  when  only  partial  primary  union  is  obtained,  the 
support  to  the  contiguous  parts  of  the  pehdc  floor  is  such  as  to  restore 
to  it  and  to  the  vagina  their  pre^dous  tonicity  and  vigor.  (2)  "When 
not  sutured  the  perineum  is  scarcely  ever  normal  or  complete.  Flaps 
of  mucous  membrane  and  ends  of  fascife,  muscles  and  nerves  are  drawn 
down  into  the  cicatrices  instead  of  being  drawn  to  the  parts  from  which 
they  were  severed ;  cicatrization  may  not  occur ;  either  subinvolution 
or  atroj^hy  of  tissues  is  apt  to  result. 

The  fact  that  the  majority  of  cicatrized  lacerations  do  not  require  a  subsequent  opera- 
tion is  no  proof  that  the  parts  would  not  be  in  a  better  condition  if  they  had  been 
successfully  repaired  by  the  primary  operation.  The  chief  reason  why  a  secondary 
operation  is  often  not  advisable  is  that  the  harm  has  all  been  done,  and  the  operation 
would  put  the  patient  to  considerable  expense  and  trouble  without  undoing  that  harm 
to  a  compensatory  degree. 

Reasons  for  Failure  of  the  Immediate  Operation. 

The  reason  why  the  immediate  operation  has  shown  so  unfavorably 
is  because  of  poor  surgery.  Superficial  parts  alone  have  been  united, 
edges  have  been  pared  so  that  the  subsequent  retraction  has  drawn 
upon  the  stitches,  proper  coaptation  has  not  been  attempted,  and  the 
wound,  although  in  an  unftivorable  place  for  cleanliness  and  aseptic 
treatment,  has  not  received  even  the  ordinary  attention  given  to  wounds 
in  other  parts  of  the  body.  Let  the  care  be  given  that  Charpentier 
recommends  for  those  not  sutured,  and  the  results  will  give  no  cause 
for  complaint. 

Contraindication  s. 

As  a  rule  it  is  useless  to  sew  a  perineum  upon  which  the  head  has 
impinged  for  hours,  since  capillary  extravasation  of  blood  has  occurred 
and  subsequent  inflammation,  suppuration,  necrosis  of  tissue,  one  or 
all,  may  be  expected  to  result.  To  operate  under  such  circumstances 
without  success  is  the  fault  of  the  operator.  The  quicker  the  passage 
of  the  head  the  better  the  chance  of  primary  union. 

A  general  condition  of  the  patient  that  would  prevent  primary  union, 


THE    OPEEATIOX.  195 

and  circumstances  that  interfere  with  approiDriate  after-treatment  are 
also  counterindications. 

The  Operation. 

The  operation  for  immediate  perineorraphy  consists  in  a  neat  and 
accurate  closure  of  the  wounded  surfaces  so  that  every  part  lies  in  di- 
rect but  unconstrained  contact  with  that  from  which  it  was  separated. 
A  needle,  silk  thread,  a  pair  of  scissors,  and  a  few  strips  of  old  linen  or 
muslin  cloth,  are  necessary.  A  needle-holder,  silkworm-gut,  two  or 
three  sharp  hooks,  a  powder-insufflator,  iodoform,  carbolic  acid,  lint, 
absorbent  cotton,  etc.,  are  desirable. 

I  generally  use  a  semicircular  needle  2^  inches  long  and  1^  from  eye 
to  point,  threaded  with  12  or  14  iron-dyed  silk,  or  with  coarse  silk- 
worm gut,  or  hardened  catgut.  A  small  piece  of  old  muslin,  wrapped 
around  the  blunt  end  of  the  needle,  may  serve  as  a  needle-holder. 

As  soon  after  labor  as  the  patient  can  be  made  clean,  not  later  than 
twelve  or  fifteen  hours,  she  should  be  placed  across  the  bed  on  her 
back  with  the  hips  at  the  edge,  and  the  knees  held  up  or  elevated. 
The  parts  are  often  so  numb  that  the  oiDcration  is  not  painful,  yet  in  a 
few  instances  an  anaesthetic  may  be  required.  A  few  drops  of  a  fifteen 
per  cent,  solution  of  cocaine  applied  to  the  wounded  surface  and  around 
the  edges  by  a  pledget  of  cotton,  and  repeated  in  four  or  five  minutes 
has  sometimes  enabled  me  within  ten  or  fifteen  minutes  to  obtain  com- 
plete local  ansesthesia.  The  vaginal  contents  are  first  allowed  to  flow 
out,  and  then  a  piece  of  absorbent  cotton  or  soft  muslin  stuffed  into  the 
vagina  and  the  cocaine  pledget  placed  in  the  wound. 

After  clipi^ing  the  hairs  from  the  labia,  wiping  out  the  vaginal  en- 
trance, ins23ecting  the  wound  and  paring  any  ragged  edges,  some  fresh 
strips  of  soft  cloth,  a  wad  of  absorbent  cotton,  or  a  small  sponge  should, 
be  introduced  beyond  the  rent.  Before  the  stitches  are  introduced 
the  edges  should  be  brought  together  to  show  just  how  they  belong.. 
Whether,  vaginal  portions  be  diagonal  or  median,  enough  vaginal 
stitches  should  be  used  to  coajDt  the  edges  perfectly.  The  point  of 
the  needle  should  be  introduced  about  one-thirty-second  of  an  inch 
from  the  edge  of  the  wound,  should  pass  not  parallel  to  its  surface,  but 
slantingly  so  as  to  grasp  deeply  into  the  retracted  ends  of  the  torn 
fibres  of  the  levator  vaginae  and  levator  ani,  then  out  over  a  small 
strip  of  the  bottom  of  the  wound,  into  the  tissues  opposite  the  point  of 
exit  and  out  again  through  the  mucous  membrane  exactly  opposite  its 
first  entrance.  The  finger  should  be  introduced  into  the  rectum  when 
a  deejD  stitch  is  introduced  in  order  to  avoid  including  it.  It  is  usually 
most  convenient  to  introduce  the  first  stitch  in  the  upper  end  of  the 
wound.  If  Ave  have  no  sharp  hooks  or  cannot,  on  account  of  the 
rounded  edges  (Fig.  117),  determine  just  where  the  upper  angle  should 
be,  we  can  put  in  a  stitch  just  behind  the  carunculee  and,  witliout  tying 


196 


LACERATION    OP    THE    PEEIXEUM    AXD    PELVIC    FLOOE. 


it,  use  it  to  draw  the  laceration  into  better  shape.  If  we  find  a  double 
diagonal  laceration  with  a  forward  extension  through  the  vulva,  we 
may  introduce  a  stitch  from  the  external  skin  along  the  extreme  upper 
edge  of  the  tear  on  the  left  side,  bringing  it  out  at  the  angle  of  junction 
of  the  median  and  transverse  portions,  catch  it  into  the  fibrous  coat  of 
the  projecting  tongue  of  the  lacerated  posterior  vaginal  wall  in  the 
median  line,  and  bring  the  point  across  to  the  opposite  labium  and  out 
through  the  skin  of  the  upper  edge  of  the  tear.  This  stitch,  like  all 
others  taken  from  the  skin,  should  enter  near  the  edges  of  the  wound 
and  pass  deep  into  the  sides  in  order  to  include  and  draw  together  the 
deeper  and  more  important  tissues.  It  should  not  be  tied  until  the 
last,  but  may  be  made  to  draw  the  wound  together  and  show  where 
the  other  stitches  belong.  When  the  stitches  are  passed  in  this  way 
near  the  edge,  there  is  less  tendency  to  compression,  eversion  and  sup- 
puration. Fig.  126  shows  the  stitch  thus  passed;  Fig.  127,  passed  in 
the  ordinary  way.     Fig.  127  also  shows  why  it  is  sometimes  necessary 


Fig.  126. 


Fig.  127. 


Fig.  126.— a.  Deep  Suture  entered  near  edge  of  Wound  to  avoid  Eversion  and  Compression;  6, 
same,  tied. 

Fig.  127.— o,  Deep  Suture  entered  at  a  distance  from  the  edge  of  Wound ;  6,  The  Same,  tied .  Com- 
pression of  edges  and  tendency  to  eversion  above  the  interrupted  line.  Primary  union  is  apt  to 
fail  above  this  line. 

to  pare  the  edges  of  the  wound,  as  in  Fig.  ]  28,  to  prevent  constric- 
tion, eversion  and  want  of  union  of  the  surface,  and  explains  the 
paradox  that  to  cut  away  the  edge  gives  a  thicker  perineal  body. 

As  each  stitch  is  passed,  starting  at  the  upper  end,  the  raw  surface 
should  be  thoroughly  cleansed,  and,  if  practicable,  touched  with  a  three 
per  cent,  solution  of  carbolic  acid  or  one  two-thousandth  solution  of  cor- 
rosive sublimate,  or  dried  and  sprinkled  with  iodoform,  and  the  stitch 
tied  tight  enough  merely  to  draw  the  parts  together.  The  anterior  ex- 
ternal stitch  must  be  the  firmest,  since  that  one  sustains  the  chief  strain 
and  protects  the  others. 

Vaginal  lacerations  in  the  median  line  may  be  united  by  a  few  fine 
stitches  or  a  continuous  catgut  suture.  Flaps  in  the  vulva  and  va- 
ginal entrance  are  similarly  stitched  to  the  opposite  side  from  which 
they  were  torn,  and  the  sides  of  the  open  cavity  under  them  brought 
together  by  the  deep  cutaneous  sutures.  Thick  flaps  are  best  united 
by  Tait's  flap  stitch.  The  needle  is  passed  into  the  flap  at  the  edge 
of  the  mucous  membrane  or  skin,  through  almost  its  entire  width, 


THE    OPERATION.  197 

then  out  across  the  bottom  of  the  wound,  into  the  opposite  side,  and 
out  again  at  the  edges  of  the  mucous  membrane  opposite  its  first  intro- 
duction.    Fig.  129  gives  a  profile  view  of  the  stitch  passed. 

If  the  sphincter  ani  is  not  ruptured,  I  first  place  the  upper  external 
stitch  at  the  very  upper  end  of  the  laceration  and  draw  the  parts  to- 
gether. It  will  then  be  easy  to  see  just  where  to  put  the  next  one  and 
how  deep  it  need  be  to  entirely  close  the  wound.  One  stitch  at  the 
top  will  seldom  hold  the  ends  of  the  transversus  perinei  unless  it  be 
placed  too  low  to  keep  the  upper  edges  together,  hence  two  or  three 
must  generally  be  used. 

If  the  sphincter  ani  be  lacerated  the  first  external  stitch  should  be 
devoted  to  it,  and  should  grasp  deeply  into  it  so  as  to  include  the 
fibres  at  the  bottom  of  the  wound  and  thus  bring  the  whole  muscle 
together.     The  next  stitch  should  be  a  little  above  it,  and  should  reach 

Fig.  128.  Fig.  129. 


Fig.  128.— a,  Edges  of  Wound  Pared  to  prevent  compression  by  stitches  and  suppuration  of  edges. 
b,  The  same,  tied. 
Fig.  129.— Flap  Stitch,  entered  into  edge  of  Flap  and  brought  out  at  opposite  edge  of  Wound. 

out  well  into  the  retracted  tissue  to  get  a  good  hold  upon  the  trans- 
versus perinei  and  restore  the  perineal  centre.  One  or  two  deep  ones 
above  these  will  usually  close  the  wound  completely,  provided  the 
vaginal  stitches  have  been  placed. 

When  thus  perfectly  coapted  under  thoroughly  aseptic  precautions, 
the  parts  adhere  almost  immediately,  and  are  quite  firm  in  four  or 
five  days,  and  as  there  is  an  abundance  of  tissue  about  the  puerperal 
genitals  there  will  be  but  little  traction  until  the  union  will  have 
become  firm. 

Although  silkworm  gut  is  hard  to  tie  properly,  I  prefer  it  for  the  main 
vaginal  stitches,  and  leave  it  from  ten  to  fifteen  days,  or  until  the 
perineal  body  is  firm.  Well-prepared  catgut  is  more  easily  used,  and 
just  as  efficient  for  the  higher  vaginal  stitches  provided  the  lower  and 
external  ones  are  properly  placed  so  as  to  sustain  all  traction.  I  have 
frequently  used  silk  for  all  sutures,  removing  them  in  four  or  five 
days,  with  equal  success.  Waxed  silk  sometimes  gives  pain  in  passing 
through  the  tissue,  but  is  easily  tied,  and  the  best  adapted  for  the  flap 
stitch.  There  is  no  object  or  justification  in  putting  the  woman 
through  the  mild  but  prolonged  torture  attending  the  use  of  silver 
sutures. 

When  the  parts  are  properly  united  the  after-treatment  is  more 
watchful  than  active.     The  knees  are  bound  together  so  that  they 


198         LACERATION    OF   THE    PERINEUM    AND    PELVIC    FLOOR. 

cannot  be  separated  more  than  ten  or  twelve  inches,  and  the  permeal 
skin  covered  by  a  folded  piece  of  iodoform  gauze,  or  lint  soaked  in  a 
ten  per  cent,  solution  of  carbolic  acid  in  castor  oil.  The  vulva  is 
cleaned  three  times  a  day  by  squeezing  hot  water  over  it  from  a  sponge, 
and  also  each  time  after  the  patient  urinates,  or  is  catheterized.  With 
such  precautions  she  may  urinate  in  a  flat  bed-pan  from  the  begin- 
ning. On  the  third  day  I  commence  vaginal  injections  of  hot  water, 
substituting  a  two  per  cent,  solution  of  carbolic  acid  as  soon  as  there 
be  found  a  decided  odor  or  appearance  of  ]3us  in  the  discharges.  The 
parts  should  be  inspected  in  a  good  light  on  the  third  and  each  suc- 
ceeding day  or  two.  On  the  third  or  fourth  day  a  dose  of  castor  oil 
or  a  mild  saline  is  given.  On  the  fifth  all  silk  stitches  are  removed 
and  the  knees  liberated  from  the  bandage,  but  the  patient  forbidden 
to  separate  them.  If  silkworm-gut  stitches  have  been  used,  they  need 
not  be  removed  for  several  days  or  a  week  later,  unless  they  are  too 
tight  and  commence  to  ulcerate. 

Frequently,  however,  there  is  more  to  do  than  this.  The  inflamma- 
tory reaction  may  go  on  to  suppuration.  If  so,  after  each  carbolated 
douche  the  labia  should  be  separated,  and  the  edges  of  the  wound 
washed  and  touched  with  a  five  per  cent,  solution  of  carbolic  acid  or 
sprinkled  with  iodoform.  If  pus  come  from  the  vagina  a  three  per 
cent,  solution  may  be  thrown  in  upon  the  stitches  with  a  little  piston 
syringe,  after  having  placed  a  little  cotton  on  the  meatus  urinarius  to 
protect  it.  A  very  small  strip  of  lint  dipped  in  carbolated  oil,  but 
squeezed  out  so  that  the  oil  will  not  get  on  the  urethra,  should  be  laid 
over  the  edges  of  the  wound  in  the  vulva,  and  on  the  external  cuta- 
neous surface.  The  parts  should  be  thus  dressed  twice  a  day  except 
that  a  three  per  cent,  solution  of  carbolic  acid  will  be  strong  enough 
after  the  first  dressing  or  two.  If  the  suppuration  increases  the  parts 
should  be  dressed  every  eight  hours. 

After  the  stitches  are  removed  the  wound  should  be  cleansed  with 
the  carbolated  water  and  protected  with  the  carbolated  oil  or  lint 
three  times  a  day,  until  suppuration  has  pretty  well  ceased,  then  twice 
a  day.  In  this  way,  even  when  the  condition  is  not  favorable,  I 
always  get  union  of  the  deeper  and  important  tissues  by  first  inten- 
tion, and  usually  of  the  whole.  In  most  cases  in  which  the  stitches 
include  much  skin,  as  in  Fig.  127,  there  will  be  a  little  suppuration 
in  the  fatty  tissue  about  the  external  cutaneous  edges,  and  occasionally 
a  little  about  the  bruised  edges  near  the  hymen,  which  scarcely  ever 
diminishes  the  length,  but  may  slightly  diminish  the  thickness  of  the 
resulting  perineal  body. 

I  have  twice  introduced  a  deep  stitch  to  hold  granulating  perineal 
surfaces  together,  but  have  only  produced  irritation  and  increased 
suppuration,  and  now  content  myself  with  binding  the  knees  and 
dressing  the  surface  as  an  open  wound.     If,  however,  we  have  a  nurse 


SECONDARY   PERINEOREAPHY.  199 

who  will  thoroughly  and  frequently  syringe  out  the  depression  or 
gutter  between  the  wounded  surfaces,  the  granulations  may  be  ex- 
pected to  meet  and  unite  more  quickly,  and  draw  the  parts  in  better 
shape,  than  without  the  stitch ;  but  without  such  attention  the  inclosed 
pus  decomposes  and  does  harm. 

Lacerations  into  the  Rectum. 

I  have  not  yet  had  an  opportunity  to  sew  up  a  laceration  opening 
into  the  rectum  by  immediate  operation,  but  consider  that  the  advan- 
tages of  an  immediate  operation  are  greater  for  such  a  lesion  than  for 
the  incomplete  variety.  As  such  a  laceration  usually  occurs  rapidly, 
and  before  much  dilatation  of  the  inferior  parts,  the  probabilities  are 
that  the  amount  of  bruising  will  not  usually  be  sufficient  to  prevent 
union  by  first  intention.  The  edges  should  be  trimmed  perfectly 
smooth,  the  parts  drawn  together  by  hooks,  and  the  shape  of  the  tear 
accurately  determined.  The  rectal  mucous  membrane  is  then  united 
accurately  by  a  continuous  catgut  suture,  or  a  series  of  silkworm-gut 
interrupted  sutures,  which  include  but  little  beside  the  rectal  mucous 
membrane.  The  remainder  of  the  rent  is  then  united  as  directed  for 
lacerations  not  extending  into  the  rectum.  It  must  be  borne  in  mind 
that  no  traction  is  allowable  on  the  rectal  stitches ;  the  vaginal  and 
cutaneous  must  be  depended  upon  for  holding  the  parts  together. 

The  after-treatment  is  the  same  as  for  the  lesser  lacerations,  except 
that  the  bowels  are  kept  constipated  for  four  or  five  days  at  least,  and 
not  disturbed  by  a  laxative  unless  a  rectal  pressure  is  complained  of 
by  the  patient.  The  less  opium  that  accomplishes  the  purpose  the 
better.  In  finally  moving  the  bowels  I  prefer  to  give  five  or  six  grains 
of  blue  mass,  followed,  if  necessary,  in  twenty-four  hours  by  a  mild 
saline,  so  as  to  give  time  for  a  softening  of  the  faeces.  If  lumps  are 
felt  in  the  rectum  they  should  be  broken  up  against  the  sacrum  by 
the  well-oiled  finger  introduced  along  the  posterior  rectal  wall.  As 
rectal  tubes  or  catheters  are  liable  to  be  directed  by  the  rectal  promon- 
tory forward  against  the  wound,  they  should  not  be  used  except  by 
the  physician.  (See  Figs.  31  and  54.)  The  silkworm-gut  vaginal 
stitches  should  be  allowed  to  remain  for  two  or  three  weeks,  and  if 
not  easily  accessible  without  stretching  the  parts,  may  be  left  two  or 
three  weeks  longer. 

Secondary  Perineorraphy. 

An  ideal  secondary  perineorraphy  should  be  the  same  as  the  imme- 
diate operation,  with  the  additional  preliminary  step  of  cutting  out 
the  cicatrices,  and  denuding  the  tissues  that  were  exposed  at  the  time 
of  the  laceration.  That  the  older  methods  of  restoring  the  vulvo- 
vaginal outlet  and  forming  a  new  perineal  body  were  unsatisfactory,  is 
attested  by  the  number,  complication,  and  confusion  of  methods  that 


200        LACERATION    OF    THE   PERINEUM    AND    PELVIC    FLOOR. 

have  been  recommended.  The  first  and  fatal  fault  consisted,  and  still 
consists,  in  treating  the  perineum  as  so  much  plastic  tissue  to  be  cut 
and  fitted  as  a  tailor  fits  a  coat.  For  the  sake  of  simplicity  it  is  also 
customary  to  recommend  one  form  or  fashion  of  perineorraphy  as  the 
usual  operation.  It  would  be  much  more  reasonable  to  recommend, 
for  the  sake  of  simplicity,  one  amputation  of  the  leg  for  all  kinds  of 
injuries  requiring  an  amputation,  for  the  leg  is  a  much  simpler  struct- 
ure than  the  perineum. 

What  is  to  be  Accomplished. 

It  is  not  only  necessary  to  remove  a  cicatricial  tissue  and  unite  torn 
surfaces  in  performing  perineorraphy,  but  to  so  unite  them  that  the 
characteristics  of  the  perineal  body  will  be  restored.  The  recto-vaginal 
promontory  must  normally  close  the  pelvic  outlet.  The  V-shape  of 
the  edge  of  the  levator  ani,  the  sling  shape  of  the  levator  vaginae,  the 
convergence  of  the  labial  tissues  at  the  fourchette,  the  size  and  pyra- 
midal shape  of  the  perineal  body,  and  the  approximation  of  the 
median  line  attachments  of  the  levator  vaginae  and  constrictor  cunni 
to  the  perineal  septum,  are  all  to  be  restored. 

WJien  to  Operate. 

The  operation  should  be  performed  as  soon  as  the  parts  can  be 
brought  into  a  healthy  state  and  the  patient's  general  health  will  per- 
mit, for  the  longer  the  delay  the  greater  the  reaction  and  atrophy  of 
tissue,  and  the  less  the  chance  of  restoring  the  contiguous  unsupported 
deeper  parts  to  their  normal  place  and  condition.     (See  Prognosis.) 

Methods  of  Restoring  the  Perineum  ivhen  the  Rectum  is  not  Opened. 

From  the  time  when  perineorrhaphy  meant  the  denudation  and 
uniting  of  a  narrow  strip  of  labial  tissue  there  has  been  a  long  series 
of  operations  devised,  many  of  which  still  survive  as  useful  thera- 
peutic measures.  Yet  none  of  them  has,  or  can,  become  the  one  ideal 
operation. 

The  Median  Triangular  Operation. 

The  oldest  of  the  surviving  methods  of  closing  the  rent  is  by  a 
triangular  denudation.  A  line  is  drawn  along  the  edge  of  the  skin 
external  to  the  laceration  from  a  point  on  one  labium  major  above 
the  lacerated  portion  to  a  corresponding  point  on  the  other  labium, 
and  two  other  lines  joining  the  ends  of  this  line  to  a  point  in  the 
median  line  of  the  posterior  vaginal  wall  above  the  cicatrix  or  relaxed 
portion  (Fig.  130).  The  surface  included  in  these  lines  is  to  be 
denuded.  Two  denuded  triangles  are  thus  formed  whose  common 
base  (the  dotted  line)  is  the  median  line.   They  to  be  brought  together 


THE    MODIFIED    TRIANGULAR    OPERATION. 


201 


SO  that  the  labial  angles  (I  I)  will  meet,  and  be  so  stitched  by  vaginal 
and  cutaneous  stitches.  By  comparing  Fig.  130  with  Figs.  114  and  115 
it  will  be  seen  that  the  denudation  corresponds  with  the  appearance  of 
certain  median  lacerations  after  labor.  This  is  the  ideal  operation  in 
median  lacerations  of  the  vulva  with  but  little  or  no  extension  into 
the  vagina.  But  as  such  lacerations  seldom  require  attention  after 
having  cicatrized,  the  operation  is  seldom  to  be  performed. 


The  Modified  Triangidar  Operation. 

In  extending  the  denuded  triangles  far  enough  up  the  posterior 
vaginal  wall  to  cover  a  median  laceration  extending  through  the  levator 
vaginse,  it  has  been  found  that  the  traction  ujDon  the  stitches  at  the  in- 
troitus  vaginse  prevents  primary  union  between  them.  In  consequence 
a  pus  pocket  forms  at  the  recto-vaginal  promontory  and  a  subsequent 
depression  remains  at  or  in  front  of  the  recto-vaginal  promontory 


Fig.  130. 


Fig.  131. 


-/Skin 


^/Jr 


Triangular  Denudation  (Schematic). 
vv,  vaginal  stitches,  not  always  required  : 
cec,  cutaneous  stitches ;  1 1,  labia. 


Modified  Triangular  Denudation  (Schematic.) 
I V,  anterior  edge  of  the  levator  vagina. 


something  like  that  in  Fig.  123.  Too  much  of  the  levator  vaginse  has 
been  excised  and  the  perineal  body  is  of  course  but  imperfectly  re- 
stored. 

In  order  to  obviate  this  the  triangles  are  made  to  extend  only  to  the 
levator  vaginse,  and  a  smaller  triangle  or  notch  is  denuded  on  the 
posterior  vaginalwall  as  far  as  desirable.  Fig.  131  shows  the  triangle 
thus  modified,  Fig,  132,  the  surface  as  it  appears  between  the  labia. 

The  reason  why  the  raw  surface  in  the  secondary  operation  is  nar- 
rower than  that  found  immediately  after  the  laceration  has  occurred, 
is  because  the  parts  are,  in  the  latter  case,  all  drawn  apart  to  an  equal 
degree  for  inspection,  whereas  when  cicatrization  occurs  the  edges  of 
the  shallow  and  but  slightly  retracted  vaginal  portion  are  drawn  over 
the  wounded  surface  in  a  proportionately  greater  extent  than  those 
of  the  many  times  deeper  and  strongly  retracted  vulval  portion. 

This  operation  is  then  the  ideal  one  for  median  lacerations  extend- 
ing up  the  posterior  vaginal  wall.  But  the  proportion  of  such  extended 
median  lacerations  requiring  a  secondary  operation  is  small. 


202 


LACEEATIOX    OF   THE    PEEIXEUM    AND    PELVIC    FLOOR. 


The  Bilateral  Operation. 

Having  noticed  from  a  study  of  the  cicatrices  that  lacerations  extend- 
ing beyond  the  vaginal  entrance  assumed  a  diagonal  direction  on  one 
or  both  sides  instead  of  following  the  median  line,  W.  A.  Freund  rec- 
ommended to  extend  the  vaginal  triangles  or  tongues  along  the  cic- 
atrices on  either  side,  and  leave  the  sound  vaginal  wall  about  the 


Appearance  of  the  Modified  Triangular  Denudation  u-  viewed  between 
the  separated  Labia  with  stitches  passed  (Zweifel.) 

median  line.  As  the  cicatrix  does  not  always  represent  the  entire  ex- 
tent of  the  tear,  he  removes  sufficient  tissue  around  it  to  normally  close 
the  vaginal  orifice.  The  resulting  raw  surfaces  have  almost  the  same 
shape  as  that  which  is  found  immediately  after  the  laceration.  Com- 
pare Fig.  117  with  Fig.  133.  The  edges  of  the  vaginal  denuded  strips 
are  first  drawn  together  (Fig.  134),  and  afterwards  the  resulting  vulval 
triangles.  Even  when  one  of  the  arms  of  the  Y  is  almost  or  entirely 
wanting  in  the  cicatrix,  a  short  strip  must  be  denuded  in  order  to 
bring  the  parts  together  symmetrically.  For  instance,  if  the  shorter 
vaginal  strip  were  entirely  gone  in  Fig.  133,  and  the  edge  of  the 
denuded  figure  were  at  the  dotted  line  instead,  it  will  readily  be  seen 


THE   BILATERAL    OPERATION. 


203 


that  the  edge  of  the  vaginal  portion  on  the  side  of  the  dotted  lines 
would  be  too  long  for  the  other  side. 

This  method  is  the  ideal  one  for  the  incomplete  Y-shaped  lacerations 
which  are  so  frequently  met  with.     Martin  has  modified  Freund's  me- 


FlG.  134. 


Bilateral  Denudation  with  stitches  passed. 
vvv,  vaginal  stitches  ;  ccc,  cutaneous  stitches ;  Z, labia. 


The  Same,  with  Vaginal  Stitches  tied. 


thod  by  extending  the  vaginal  tongues  deep  into  the  vagina  and  the 
vulval  denudations  higher  up.     It  is,  however,  intended  more  as  an 


Martin's  Modification  of  the  Bilateral  Denudation. 


operation  for  prolapse  when  the  parts  cannot  be  permanently  restored 
to  their  normal  relations,  and  gives  a  small  firm  vaginal  entrance. 
(See  Fig.  135.) 


204        LACERATION   OF   THE   PERINEUM   AND   PELVIC   FLOOR. 


Crescent  Operation. 

As  in  many  cases  the  vaginal  entrance  only  is  lacerated,  the  cicatrix 
may  be  removed  and  the  lacerated  parts  united  by  removing  a  crescent 
from  the  vulvo-vaginal  entrance  whose  angles  extend  into  the  posterior 
vaginal  sulci  or  grooves  (Fig.  136).  The  centre  of  the  convex  external 
edge  of  the  crescent  reaches  almost  or  quite  to  the  fourchette.  The 
centre  of  the  concave  inner  edge  is  at  the  lower  end  of  the  sound 
posterior  vaginal  walls  behind  the  cicatrix,  or  in  the  absence  of  a 
cicatrix  it  is  located  just  below  the  median  line  attachment  of  the 
levator  vaginse.  The  angles  of  the  crescent  include  the  cicatrices  of 
the  diagonal  laceration. 

The  stitches  are  so  placed  as  to  draw  the  two  edges  together  com- 
mencing at  the  angles  (Fig.  137).  When  they  are  drawn  together  a 
labial  notch  is  left  from  the  longer  side  of  the  crescent  to  be  united  by 
one  or  more  sutures. 

This  is  the  ideal  operation  for  the  V-shaped  lacerations.  It  draws 
together  the  torn  edges  of  the  levator  vaginae,  or  shortens  it  if  it  be 


Fig.  136. 


Fig.  ]37. 


Fig.  138. 


W 


--^Fazrjrchette^ 


yyytejtr 


^^: 


JT^ZtS 


(The  laceration  is  supposed  to 


IhtS 


Fig.  136.— Crescentic  Denudation  with  Vaginal  Stitches  passed, 
have  been  larger  on  patient's  left  side.) 

V,  vagina;  ss,  sulci  of  post- vaginal  wall. 

Fig.  137.— The  Same,  with  Vaginal  Stitches  tied. 

Fig.  138.— Crescentic  Denudation  modified  to  close  a  Transverse  Laceration  without  narrowing 
the  Vulva.  Same  lettering  as  Fig.  136.  (The  laceration  is  a  little  larger  on  left  side  (of  patient) 
than  on  right.) 

relaxed  from  diffuse  laceration ;  it  restores  the  recto- vaginal  end  of  the 
raphe;  and  it  brings  together  the  separated  ends  of  the  constrictor  cunni 
in  case  that  has  been  reached  by  the  tear.  Much  or  little  vulval  tissue 
may  be  included,  and  the  labial  notch  left  after  passing  the  vaginal 
stitches  may  be  increased  if  the  vulva  remain  too  much  relaxed. 
When  the  V  is  very  wide  open  or  the  rent  is  a  transverse  one  with 

a  slight  diagonal  extension  on  either  end  {\ •  x      x)^  it  is  better  to 

place  the  ends  of  the  external  convex  curve  low  down  at  the  outer 
side  of  the  sulci,  and  make  the  inner  curve  pass  deeper  into  the  sulci 
and  then  turn  back  to  meet  it.  Thus  the  inner  side,  b}^  the  extra  con- 
vex curve  at  each  end,  becomes  as  long  as  the  external  side,  and  may 
be  united  without  leaving  a  redundancy  anywhere  (Fig.  138). 


emmet's    crescent   operation — STAR   OPERATION.  205 

Emmet^s  Crescent  Operation. 

Emmet  operates  upon  posterior  colpocele  and  rectocele  by  drawing 
without  undue  traction  the  crest  of  the  rectocele  and  the  two  lower 
caruncles  together  by  tenacula,  denuding  the  tissue  thus  folded 
together  as  far  into  the  sulci  as  the  folds  extend,  and  uniting  the  edges 
of  the  resulting  figure  in  the  shape  of  a  crescent  by  stitches  "  passed 
in  a  direction  from  the  centre  towards  the  circumference,"*  somewhat 
as  in  Fig.  137. 

This  operation  holds  about  the  same  relation  to  the  operation  just 
described  as  Martin's  operation  does  to  Freund's.  It  removes  the 
vaginal  tissue  that  cannot  be  replaced  and  closes  the  vaginal  entrance 
to  the  desired  extent.  Its  chief  peculiarity  is  that  it  unites  the  ends 
of  the  levator  ani  (from  which  a  median  piece  has  been  removed)  to 
the  vulval  tissues,  instead  of  to  each  other  in  the  median  line.  The 
danger  lies  in  drawing  down  the  relaxed  levator  vaginae  so  that  too 
much  of  it  will  be  removed. 

It  is  a  good  operation  for  uncicatrized  lacerations  through  the  peri- 
neal raphe  that  have  resulted  in  rectocele,  and  prolapse  of  the  posterior 
vaginal  wall,  to  an  extent  that  cannot  be  remedied  by  anything  short 
of  cutting  off  the  protruding  vaginal  tissues.  It  is  also  an  excellent 
procedure  for  transverse  lacerations  through  the  raphe,  with  or  with- 
out rectocele,  in  which  the  levator  vaginae,  although  torn  loose  from  the 
rest  of  the  perineum,  is  not  relaxed.  It  will  not  then  be  pulled  far 
enough  down  to  be  involved  in  the  denudation,  and  will  be  reattached 
to  the  perineal  body  and  vulva. 

Transverse  Denudations. 

A  transverse  laceration  at  the  vaginal  entrance,  whether  superficial 
or  submucous,  cicatrized  or  not,  should  be  closed  by  a  transverse  strip 
from  half  to  one  inch  wide  along  the  cicatrix,  or  by  a  removal  of  the 
whole  of  the  relaxed  tissue  between  the  levator  vaginae  and  constrictor 
cunni.  The  width  of  the  strip  is  determined  by  the  amount  of  pro- 
trusion between  the  muscles  or  by  pressing  them  apart  by  the  finger 
in  the  rectum.     The  stitches  are  passed  antero-posteriorly. 

That  such  a  denudation  would  cure  any  considerable  misplacement 
of  the  parts  above  is  scarcely  to  be  expected,  for  the  amount  of  relax- 
ation of  the  levator  vaginae  and  constrictor  cunni  is  usually  such  that 
a  shortening  of  these  muscles  and  a  removal  of  redundant  vaginal 
tissues  is  required. 

Star  Operation.  , 

When  such  is  the  case  a  median  triangular  or  bilateral  figure  may 
be  drawn  across  the  transverse  strip  (Figs.  139  and  140).  .  The  edges 
of  the  longitudinal  vaginal  strips  are  first  brought  together  by  trans- 

*  Am.  Journal  of  Obstetrics,  vol.  xviii.,  p.  173. 


206         LACERATION   OF   THE   PERINEUM    AND    PELVIC   FLOOR. 

verse  stitches,  then  those  of  the  transverse  strips  by  stitches  passed 
antero-posteriorly,  and  finally  the  vulval  portions.  When  but  little 
or  no  laceration  of  the  vulval  tissues  exists  the  vulval  denudation 

Fig.  139.  Fig.  140. 


7^  Amis 

star  Denudations  for  complication  of  Transverse  Lacerations  with  other  varieties- 
Sutures  passed. 
The  interrupted  lines  indicate  the  shape  of  the  larger  labial  denudation  when  required. 

may  be  reduced  to  a  small  triangle,  or  nick,  whose  apex  is  at  the  foar- 
chette  or  posterior  commissure  of  the  labia  majora ;  or  the  labial  de- 
nudation may  be  left  out  altogether. 

The  following  cicatrices  taken  from  the  table  on  pages  175  how  some 
of  the  lacerations  for  which  this  form  of  denudation  is  applicable. 

■Y-A^^^^-H-  +T  J. 

As  a  rule  the  star-shaped  denudations  should  give  way  to  the  sim- 
pler forms  when  the  latter  can  be  made  to  remove  cicatricial  and  use- 
less tissue  only,  and  restore  the  natural  relation  of  the  parts.  In  some 
cases  the  crescent  denudation,  or  Emmet's,  or  Freund's  bilateral  can 
be  made  to  answer.  But  a  simpler  form  should  never  be  preferred  on 
purely  mechanical  principles,  to  the  sacrifice  of  anatomical  and  physi- 
ological desiderata. 

Flaip  Operations. 

One  reason  of  the  imperfect  results  attained  in  secondary  peri- 
neorrhaphy is  that  traction  upon  the  edges  is  caused  by  a  cutting 
away  of  too  much  superficial  tissue.     This  may  be  avoided  by  raising 

flaps. 

The  Triangular  Flap  Operation. 

The  simplest  form  of  flap  operation  is  that  devised  by  John  Duncan, 
of  Edinburgh ,^^  and  which  is  practically  a  modified  median  triangular' 
operation.  An  incision  is  made  in  the  median  line  from  the  upper 
end  of  the  laceration  in  the  posterior  vaginal  Avail  to  the  posterior  com- 
missure, or  as  far  back  toward  the  anus  in  the  median  line  as  the 
laceration  may  extend.     From  the  lower  end  of  this  median  incision, 

*  Hart  and  Barbour,  Manual  of  Gynecology. 


BISCHOFF  S    OPERATION. 


207 


one  is  made  on  each  side  along  the  vulval  border  of  the  laceration 
to  a  point  on  the  labium  major  as  high  as  the  denudation  is  to  ex- 
tend. A  flap  is  then  dissected  up  on  each  side  whose  edges  are  these 
incisions.  In  Fig.  141  c  6  is  the  median  incision,  and  a  b  the  external. 
a  b  c  forms  the  flap  to  be  raised  up  as  far  as  a  c.  The  flaps  are  raised, 
trimmed,  and   stitched   together   in  the   median  line   by  superficial 


Fig.  141. 


Fig.  142. 


Fig.  141.— Lines  of  Incision  in  the  Triangular  Flap  Operation.    (Hart  and  Barbour.) 
a  6,  labial  incisions ;  c  6,  median  line  incision  passing  to  posterior  vaginal  wall ;  abc,  flap  to  be 
raised. 
Fig.  142. — Flaps  Raised  and  Sutures  Passed  in  same  Operation.    (Hart  and  Barbour.) 

stitches,  and  then  the  labia  brought  together  by  ordinary  deep  cuta- 
neous sutures.  Fig.  142  shows  the  sutures  passed.  Lawson  Tait 
merely  turns  the  flaps  into  the  vagina  without  stitching  them,  and  then 
passes  the  deep  sutures  under  the  edges  of  the  skin  so  that  after  they 
are  tied  none  of  the  threads  but  the  knotted  portions  at  the  edge  of 
the  wound  are  visible. 


Bischoff^s  Operation. 

In  Bischoff's  operation  a  denudation  is  made  similar  to  Freund's 
(Kuestner*)  except  that  the  tongue  of  vaginal  tissue  left  in  the  median 
line  is  narrow,  and  the  denuded  strips  on  either  side  are  wider  and 
nearer  together.  Then  the  tongue  of  the  posterior  vaginal  wall  is  dis- 
sected up  and  brought  forward  over  the  median  line  raphe,  stitched 
between  the  labia  and  lateral  walls,  and  the  perineum  united  by  deep 
external  sutures,  commencing  behind.     Fig.  143  represents  the  figure 


*  Zeitschrift  f.  Geb.  und  Gyn.,  xiii.,  1. 


208         LACERATIOX    OF    THE   PERINEUM   AND    PELVIC    FLOOR. 

to  be  denuded;  Fig.  144  the  denuded  figure  after  tlie  flap  has  been 
drawn  forward. 

The  operation,  like  Martin's,  is  more  of  an  operation  for  prolapse 
than  for  restoring  a  normal  condition  of  the  perineum.  The  denuded 
figure  extends  far  out  on  the  labia  and  near  the  anus. 

Fin.  14?..  Fig.  144. 


Denudation  as  made  by  Bischoff.  The  Same,  with  Flap  Raised  and 

drawn  forward. 

Modified  Freimdh  Operation. 

Freund's  operation  is,  I  think,  improved  by  cutting  away  only  the 
cicatricial  tissue,  and  raising  a  short,  thick  flap  from  the  wide  tongue 
of  the  posterior  vaginal  wall  in  the  median  line.  The  flap  should 
commence  at  the  upper  end  of  the  denuded  vaginal  strips  on  the 
median  side  and  gradually  increase  in  width  and  thickness  until  at  the 
end  it  is  from  a  quarter  to  a  third  of  an  inch  wide.  This  must  be 
stitched  well  forward  toward  the  fourchette,  and  will  make  up  for  the 
previous  retraction  of  the  posterior  vaginal  wall.  It  is  also  well,  when 
the  denudation  extends  laterally  beyond  the  cicatrix,  to  leave  the 
normal  membrane  and  raise  a  narrow  thick  flap  at  the  sides.  This 
enables  us  to  get  a  firm  deep  hold  upon  the  levator,  and  without  undue 
traction  upon  the  levator  vaginse  and  mucous  membrane,  such  as  must 
result  from  a  wide  superficial  denudation. 

The  upper  end  may  be  united  by  superficial  catgut  sutures,  but  that 
near  the  hymen  requires  one  or  two  deep  stitches,  preferably  flap 
stitches,  one  each  side.  The  cutaneous  stitches  must,  of  course,  bring 
the  tissue  external  to  the  hymen  in  apposition.  The  anterior  or  upper 
one  should  be  placed  well  forward,  and  may  grasp  the  flap  of  vaginal 
wall  just  under  the  mucous  membrane. 

Crescentic  Flap  Operation. 

The  crescent  operation  already  described  may,  when  done  for  a 
V-shaped  laceration,  be  usually  performed  as  a  flap  operation.  The 
vaginal  tongue,  and  if  necessary  the  opposite  edges,  are  dissected  up 
as  flaps  the  same  as  just  described  for  converting  Freund's  bilateral 
operation  into  the  flap  variety.  The  flap  is  then  stitched  to  the 
anterior  curve  of  the  crescent,  either  as  in  Fig.  136  or  138. 


UNILATERAL    FLAP   OPEEATION. 


209 


Unilateral  Flap  Operation. 

The  S-shaped  lacerations  at  one  side  of  the  median  line  (Fig.  113) 
are  usually  flap  lacerations,  and  the  edge  of  the  flap  is  usually 
drawn  or  turned  in  at  the  edge  of  the  cicatrix.  In  this  case  a  line  is 
drawn  along  the  edge  of  the  vulval  skin  and  mucous  membrane  at 
the  median  side  of  the  cicatrix  from  the  external  skin  as  far  up  the 
posterior  vaginal  sulcus  as  it  goes.  (See  Fig.  145.)  The  denudation 
is  carried  from  this  line  laterally  so  as  to  remove  the  entire  cicatrix. 
If  the  denudation  is  then  not  high  enough  on  the  side,  the  vaginal 
wall  and  vulval  skin  are  dissected  up  as  a  narrow  thick  flap.  Then, 
instead  of  removing  any  more  tissue  the  vulval  skin  and  mucous 
membrane  are  dissected  up  as  a  flap  /,  toAvard  the  opposite  side  as 


Fig.  145. 


Unilateral  Flap  Denudation. 
V  I' i;  2)  z),  vaginal  flap  sutures;  vl,'vl,y\i\v&\  superficial  sutures;  c  c  o,  cutaneous  deep  sutures, 
passed  under  flap  (/)  after  the  vaginal  and  vulval  stitches  have  been  tied ;  /,  flap.    The  inter- 
rupted lines  on  either  side  show  extent  of  denudation  under  the  flap/,  and  the  edge  opposite. 


far  as  the  laceration  is  known  to  have  extended,  or  sufficiently,  when 
the  surfaces  are  united,  to  restore  the  size  to  the  vaginal  entrance  and 
perineal  body.  The  interrupted  lines  on  both  sides  show  the  extent 
of  denudation  under  the  flaps.  As  the  bottom  of  the  laceration  is 
mainly  on  one  side,  the  denudation  must  be  so. 

The  edge  of  the  flap,  however,  usually  comes  out  longer  than  the 
other  side.  This  is  remedied  by  making  the  top  of  the  laceration  at 
the  inner  side  of  the  vaginal  strip  and  placing  the  stitches  so  as  to 
draw  in  the  flap  toward  the  larger  curves  of  the  other  side  from  where 
it  has  been  prolapsed.  I  have  noticed  this  same  disproportion  in  the 
length  of  the  sides  in  sewing  up  such  lacerations  after  labor,  and  have 
remedied  it  in  the  same  way,  and  without  removing  any  tissue. 

At  the  vaginal  end  and  in  the  labia,  superficial  catgut  stitches  may 
be  used  to  unite  the  edges  of  the  flap,  but  at  the  hymen  and  levator 
vaginae  one  or  two  deep  flap  stitches  are  of  advantage.     The  external 

14 


210        LACEEATION    OF   THE    PERINECJM    AND    PELVIC   FLOOR. 

stitches  should,  as  in  the  modified  Freund's  operation,  be  made  to 
close  the  parts  as  deej)  as  the  hymen. 

Operations  upon  Uncicatrized  Lacerations. 

Sometimes  it  is  possible  to  diagnose  the  character  of  an  uncicatrized 
laceration  from  the  appearance  of  the  mucous  membrane.  But 
usually  it  is  necessary  to  diagnose  the  amount  of  primary  relaxation 
and  displacement,  as  distinguished  from  the  secondary  relaxation  and 
displacement  in  the  uninjured  parts.  Having  then  calculated  or  as- 
certained by  direct  palpation  just  how  and  where  the  lesion  occurred, 
the  apj)ropriate  ojDeration  can  be  chosen,  to  restore  the  separated  j^arts 
to  their  original  relationship. 

Lacerations  Lnvolving  the  Sphincter  Ani  bid  not  the  Rectum. 

When  the  laceration  extends  into  or  through  the  sphincter  ani  but 
not  through  the  cutaneous  membrane  lining  the  anal  canal,  the  denu- 
dations are  made  the  same  as  if  the  sphincter  were  not  invaded.  But 
greater  care  must  be  taken  that  the  first  stitch  be  introduced  far 
enough  back  beside  the  anus  to  catch  into  the  whole  thickness  of  the 
retracted  sphincter.  The  next  stitch  should  be  just  at  the  external 
edge  of  the  sphincter.  Above  that  they  are  passed  as  in  other  smaller 
lacerations. 

Closure  of  Lacerations  Extending  a  Short  Distance  into  the  Rectum. 

Lacerations  passing  through  the  sphincter  into  the  anus  and  rectum 
need  more  careful  attention  in  getting  the  parts  about  the  anus  in  ap- 
position, but  otherwise  may  be  united  very  much  as  already  described 
for  the  incomplete  varieties. 

The  denudation  should  include  the  edges  of  the  rectal  rent  and  the 
vaginal  cicatrices,  and  should  extend  to  the  edges  of  the  strijD  of  anal 
skin  lying  upon  the  opened  and  straightened  sphincter  at  the  bottom  of 
the  field.  The  vaginal  denudation  must  be  extensive  enough  for  the 
needle  to  reach  the  lacerated  ends  of  the  levator  ani  on  one  or  both 
sides  of  the  rectum. 

Hegar  applies  the  principle  of  the  median  triangular  operation. 
The  figure  when  denuded  has  a  butterfly  shape  (Fig.  146).  Closure  of 
the  rectal  rent  alone  would  leave  the  figure  of  the  shape  of  the  modi- 
fied triangular  operation  for  incomplete  lacerations  (Fig.  132).  The 
rectal  and  vaginal  stitches  are  placed  in  the  deeper  portions  so  as  to  close 
the  upper  part  of  the  tear  both  in  the  vaginal  and  rectal  side.  This 
gives  the  operator  an  opportunity  to  place  some  of  each  deep  and 
some  superficial,  according  as  he  wishes  to  elevate  or  support  the  tis- 
sues. The  objection  to  this  method  is  that  the  tears  are  seldom  median, 
and  healthy  tissues  are  removed  and  cicatrices  left.     An  equally  valid 


FLAP   OPERATIONS. 


211 


objection  is  that  it  does  not,  unless  the  vaginal  strip  be  too  wide,  give 
a  hold  in  the  levator  ani  fibres  beside  the  rectum ;  and,  therefore, 
although  exerting  great  traction  upon  the  vaginal  entrance  and  levator 
vaginse,  does  not  raise  the  pelvic  floor  edge  or  rectal  promontory,  and 
thus  does  not  sufficiently  protect  the  perineum  against  the  reflected 
abdominal  pressure. 

Freund's  bilateral  denudation  is  applicable  when  the  bilateral  vagi- 
nal laceration  is  found  (Fig.  147).     The  rectum  is  first  sewed  up  by 


Fig.  146. 


Fig.  146.— Hegar  Triangular  Denudation  applied  to  Lacerations  extending  info  Rectum. 

V,  vaginal  wall ;  I,  labia. 

Fig.  147.— Freund's  Bilateral  Denudation  (Kuestner)  for  Laceration  into  Rectum. 

1 1,  labia ;  v,  vaginal  wall  (posterior) ;  r,  rectal  mucous  membrane ;  c,  vaginal  denudation 
around  cicatrix  ;  n,  nick  of  tissue  removed  to  render  the  vaginal  edges  more  symmetrical.  The 
shaded  portion  indicates  the  size  and  shape  of  the  cicatricial  tissue. 


stitches  extending  only  one-third  through  the  septum,  and  then  the 
vaginal  by  stitches  extending  about  two-thirds  through.*  When  only 
one  arm  of  the  Y  extends  up  the  vagina,  a  compensating  small  strip 
may  be  denuded  on  the  sound  side.     (See  Bilateral  Operation.) 

The  first  external  stitch  should,  as  pointed  out  by  T.  A.  Emmet,  be 
introduced  below  and  a  little  internal  to  the  ends  of  the  sphincter  in 
order  to  get  a  deep  hold  of  the  fibres,  and  should  pass  obliquely  to  the 
edge  of  the  anus  across  the  strip  of  the  anal  skin  into  the  edge  of  the 
muscle  and  out  at  a  corresponding  point  opposite.  As  the  course  of 
the  needle  is  not  straight,  great  care  must  be  taken  to  penetrate  deeply 
into  the  muscle.  The  next  suture  is  passed  opposite  the  outer  edge  of 
the  sphincter  and  catches  up  the  external  fibres.  Above  this  they  are 
passed  in  the  ordinary  way. 

Flap  Operations. 

John  Duncan,  A.  R.  Simpson,  Lawson  Tait,  and  Hart  and  Barbour 
close  these  operations  by  a  modification  of  the  triangular  flap  opera- 
tion.    They  make  a  labial  incision  from  the  posterior  edge  of  the  end 


*  Kuestner  Zeitschr.  fur  Geburtsh.  u.  Gyn.,  vol.  xiii.,  No.  1. 


212 


LACEEATION    OF    THE   PERINEUM   AND    PELVIC    FLOOR. 


of  the  anal  sphincter  (Fig.  148,  b)  up  along  the  outer  edge  of  the 
laceration  as  in  the  incomplete  variety.  Another  incision,  S  1,  is  made 
on  each  side  from  the  top  or  apex  of  the  rectal  opening,  along  the 
recto-vaginal  septum  to  the  first  incision,  a  b,  so  as  to  pass  across  the 
perineal  hody  a  little  in  front  (or  above)  the  edges  of  the  anal  skin. 
The  recto-vaginal  septum  is  split  by  knife  or  scissors  at  the  apex  of 
the  rectal  opening  along  the  line  of  the  incision,  and  flaps  raised  both 
in  front  and  behind  it.  The  anterior  flap,  a  1  S,  is  raised,  pared  and 
attached  by  superficial  sutures  to  its  opposite,  to  constitute  the  poste- 
rior vaginal  wall,  fourchette  and  posterior  commissure  of  the  labia. 


Fig.  148. 


Fig.  149. 


Fig.  148.— Lines  of  Incision  of  the  Triangular  Flap  Operation  applied  to  Lacerations  extending 
into  Eectum.    (Hart  and  Barbour.) 

a  1 S,  flap  to  be  raised  and  united  to  its  opposite  to  form  posterior  vaginal  wall ;  6  25,  flap  to  be 
raised  and  united  to  its  opposite  to  form  anterior  rectal  and  anal  wall. 

Fig.  149.— Flaps  raised  and  Sutures  passed  in  same  Operation.    (Hart  and  Barbour.) 


The  posterior  flaps  b2S are  united  over  the  rectum  to  constitute  the 
anterior  rectal  and  anal  walls.  Fig.  149  shows  the  flaps  raised  and 
united.  The  sides  of  the  perineum  are  brought  together  by  superflcial 
and  deep  sutures.  Tait  turns  the  anterior  flaps  into  the  vagina  and 
the  posterior  into  the  rectum  without  the  superficial  stitches. 

This  method  of  denudation  is  useful,  but  from  a  strictly  scientific 
standpoint  is  only  applicable  to  cases  of  median  lacerations  into  the 
rectum,  which  are  the  exceptional  ones. 

By  cutting  a^vay  the  cicatricial  tissues  from  the  vulva  and  vagina 
and  then  raising  flaps,  the  largest  one  from  the  side  opposite  the  uni- 
lateral diagonal  vaginal  extension,  the  principle  of  the  unilateral  flap 
operation  (Fig.  145)  can  be  applied  (Figs.  150,  151,  152  and  153). 


FLAP   OPEEATIONS. 


213 


Thus  the  vaginal  Hue  of  sutures  at  the  recto-vaginal  promontory  will 
be  diagonal,  that  of  the  vulva  slightly  diagonal  while  that  of  the  rectum 
will  be  almost  median. 


Fig.  150. 


Fig.  151. 


JI/[]iB.latij  Tina 


'iiiv 


Fig.  150.— rnilateral  Flap  Operation  applied  to  Lacerations  into  Rectum.  Rectal  superficial 
sutures  (r  s)  passed ;  vf,  flap  raised  from  posterior  vaginal  wall.  The  interrupted  line  shows  how 
far  the  flap  is  raised. 

Fig.  151.— The  Same.    Rectal  sutures  tied,  flap  stitches  (fs)  passed. 

When  the  vaginal  rent  is  bilateral  two  strips  should  be  denuded  and 
the  tongue  of  vaginal  tissues  in  the  middle  raised  around  its  edges. 


Fig.  152. 


Fig.  153. 


of 


Fig.  152.— The  Same.   Vaginal  Flap  Sutures  Tied.   Vulval  superficial  sutures  {&&)  passed.    Cuta- 
neous deep  sutures  (c  s)  passed. 
Fig.  158.— Vulval  Sutures  Tied.    Lower  cutaneous  stitch  (through  the  sphincter)  tied. 


214 


LACERATION    OP    THE   PERINEUM    AND    PELVIC    FLOOR. 


After  closure  of  the  rectum  by  superficial  stitches  it  is  closed  the  same 
as  recommended  for  the  modified  Freund's  operation  for  incomplete 
lacerations  (p.  208). 

Bischoff' s  Flap  Operation  has  been  applied  with  some  success  to 
the  complete  lacerations.  After  closure  of  the  rectal  opening  the  flap 
is  brought  forward  (p.  207). 

Langenbeck's  operation,  which  is  the  oldest,  is  similar  to  the  last. 
The  edge  of  the  recto- vaginal  septum  is  denuded  and  then  split  for 
some  distance.  A  flap  is  then  simply  cut  out  of  the  vaginal  side  and, 
after  closure  of  the  rectum,  is  stitched  forwards  over  the  new  perineum 
by  vaginal  stitches.  The  external  stitches  are  placed  from  before 
backward. 

Lacerations  Extending  High  up  into  the  Rectum. 

Lacerations  deep  into  the  rectum  usually  pass  on  one  or  both  sides 
of  the  median  line,  as  the  S,  V  or  Y-shaped,  whereas  in  the  lesser  forms 
of  rectal  lacerations  the  rectal  portion  is  rounded  and  may  be  treated 
as  a  median  one. 

Fig.  154. 


Emmet's  Method  of  passing  the  Sutures  in  case  of  a  Bilateral  Diagonal  Laceration  extending 
through  the  Recto- Vaginal  Septum. 

In  such  a  case  it  is  all  the  more  necessary  that  the  denudation  follow 
the  lateral  cicatrices  in  order  not  to  remove  the  healthy  tissue. 
Freund's  method  is  the  same  as  just  described  (p.  211)  except  that 
more  rectal  stitches  are  required. 

Emmet  removes  the  tongue  of  vaginal  tissue,  denudes  beyond  both 
rectal  tears  on  the  sides,  and  then  draws  the  whole  together  by  stitches 
passed  completely  across  and  directly  through  the  tongue  of  rectal 
mucous  membrane  (Fig.  154). 


CHOICE   OF    METHODS. 


215 


Tait  o]3erates  upon  these  deep  rectal  lacerations  by  splitting  the 
recto-vaginal  septum  (without  removing  any  tissue)  into  thick  flaps. 
He  introduces  the  stitches  at  the  vaginal  edge  of  the  raw  surfeces 
parallel  with  the  surface  of  the  flap,  carries  them  into  the  deeper 
structures  and  out  at  the  rectal  flap,  introduces  them  at  the  rectal 
flap  opposite  and  brings  it  out  at  the  vaginal  edge.     In  this  way  a 


Fig.  155. 


Splitting  of  the  Perineum  and  Recto-Vaginal  Septum  with  Flap  Stitches  passed,  after  the  manner 
of  Lawson  Tait.    Copied  from  Billroth  and  Luecke's  Handbuch  der  Frauenkrankheiten. 

large  surface  is  united,  the  deeper  structures  are  brought  together, 
the  rectal  edges  protected  by  the  folding  flaps  and  the  operation  very 
much  simplified.  The  results  are  generally  conceded  to  be  good. 
Fig.  155  represents  the  stitches  passed.  The  external  parts  are  united 
similarly.    ' 

Choice  nf  Methods. 

The  surgeon  should  vary  his  method  according  to  the  case,  and  be 
guided  by  the  amount  of  displacement  and  destruction  of  parts,  and 
the  shape  and  character  of  the  cicatrix.  The  cicatrix  should  as  a  rule 
be  excised  and  the  denudation  completed  by  the  raising  of  flaps.     Old 


216 


LACERATION    OF    THE    PERINEUM   AND    PELVIC   FLOOR. 


cases  may  present  so  much  shrinkage  and  retraction  that  flaps  must 
be  made  of  the  cicatricial  tissue.  Flaj)S  made  in  part  of  cicatricial 
tissue  should  generally  be  united  by  the  Tait's  flap  stitch ;  flaps  of 
healthy  mucous  membrane  by  ordinary  superficial  stitches  in  the 
vulva,  and  deep  or  flap  stitches  in  the  vaginal  entrance. 

Preparation  of  the  Patient. 

For  a  week  before  an  operation,  in  a  case  in  which  the  rectal  sphinc- 
ter is  involved,  a  mild  laxative  should  be  administered  every  two  or 
three  nights,  supplemented  if  necessary  by  daily  enemas.  A  drachm 
of  Comp.  Tinct.  Cardamom,  or  a  grain  of  Piperin  combined  with  a 
third  of  a  grain  of  extract  of  nux  vomica,  may  also  be  advantageously 
given  every  night  for  four  or  five  nights  before  the  operation.  The 
diet  throughout  the  week  should  be  light  and  easily  digestible.  On 
the  day  before  the  operation  the  colon  should  be  as  completely 
emptied  as  possible  by  two  or  three  copious  enemas  of  weak  soapsuds, 
or  glycerine  and  water  in  the  proportion  of  one  to  ten  or  fifteen.  If 
the  contents  of  the  colon  be  not  brought  down,  the  enemas  should  be 
given  in  the  knee-chest  i30sition.  After  each  evacuation  the  genitals 
should  be  bathed  with  water,  and  anointed  with  some  simple  oint- 
ment. The  last  enema  should  be  of  plain  water,  and  should  be  given 
from  three  to  twelve  hours  before  the  operation.  A  little  later  a  small 
dose  of  an  opiate  with  an  aromatic  should  be  given  to  protect  the 
rectum  and  anus  against  the  seeping  of  watery  faeces. 

When  the  sphincter  ani  has  not  been  lacerated,  nor  the  rectum 
opened  at  any  point,  all  of  this  treatment  may  be  dispensed  with.  A 
thorough  evacuation  of  the  bowels  the  day  before,  and  an  enema  two 
or  three  hours  before  the  operation  will  be  sufficient. 


Preparations  for  Operating. 

The  instruments  necessary  are  a  scaljDel,  a  pair  of  sharp-pointed 
long-handled  scissors,  small  and  large  curved  needles,  three  tenacula, 


Fig.  156. 


Perineum  Scissors 


dressing-forceps,  sponge-holder,  needle-holder,  catgut,  silkworm-gut, 
wax,  heavy  and  fine  silk,  silver  wire,  wire-twister,  sponges,  three  or 
four  of  the  Langenbeck  serres-fines  for  compressing  arteries. 


OPEEATIVE    DETAIL. 


217 


We  should  have  an  assistant  for  the  ana3sthetic,  two  to  support  the 
knees,  separate  the  labia  and  hold  tenacula,  and  another  for  instru- 
ments and  sponges. 


Fig.  15 


Langenbeck  Serres-flne  for  Compressing  Arteries  during  the  Operation. 

The  patient  should  be  placed  in  the  dorsal  position  with  the  knees 
drawn  up.  The  operator  should  be  comfortably  seated  with  a  good 
light  shining  over  his  shoulders,  and  his  instruments  on  a  table  at  his 
right  within  easy  reach. 

Operative  Detail. 

Before  commencing  the  denudation  the  operator  should  ascertain 
by  palpation  just  what  parts  are  out  of  place  and  relaxed,  and  by 
hooking  the  tissues  together  with  tenacula  how  they  can  be  best 
brought  into  place.  Having  then  determined  by  inspection  of  the 
cicatrix  and  attenuated  tissues  what  portion  is  to  be  excised  and  what 
to  be  turned  up  as  flaps,  an  incision  around  that  to  be  removed  is 
made,  and  after  its  removal  an  incision  along  the  edge  of  the  flaps  to 
be  dissected  up.  Flaps  should  not  extend  into  the  muscular  tissues 
unless  there  be  cicatrized  tissue  or  other  evidence  of  an  oblique  lacera- 
tion into  it,  as,  for  instance,  in  the  unilateral  flap  laceration. 

It  is  better  to  begin  the  denudation  at  the  lower  superficial  parts 
which  do  not  bleed  as  profusely  nor  soil  the  parts  to  be  denuded 
above.  Large  vessels  may  be  clamped  by  the  serres-fines,  or  they 
may  be  tied  with  fine  catgut,  and  thus  time  for  a  careful  preparation 
of  the  surfaces  be  gained. 

After  having  performed  the  same  operation  a  number  of  times,  the 
outlining  of  the  part  to  be  denuded  will  be  unnecessary,  and  the 
denudation  can  be  so  rapidly  made,  that  little  trouble  will  be  experi- 
enced from  the  hemorrhage.  Experience  may  often  enable  us  to 
prepare  the  deeper  vaginal  portion  first,  and  unite  the  edges  before 
going  any  farther,  as  Martin  recommends  in  his  Elytrorrhaphia 
Duplex  Lateralis. 

Either  the  knife  or  the  scissors  may  be  used  for  removing  or  raising 
the  tissues.  With  the  latter  we  can,  however,  work  more  rapidly  and 
with  less  hemorrhage.  Various  special  forms  of  knives  have  been 
invented,  but  have  failed  to  come  into  general  use. 

After  the  surface  has  been  prepared  it  is  well  to  bring  the  parts  into 
apposition  by  tenacula.     If  they  do  not  fit  to  each  other  they  may 


218         LACERATION    OF    THE   PEEIXEUM    AXD    PELVIC    FLOOPv. 

then  be  made  to  do  so.  But  the  great  mistake  should  never  be  made 
of  trying  to  increase  the  size  of  the  perineal  body  beyond  the  normal 
by  remo^dng  healthy  skin  and.  mucous  membrane,  for  the  traction 
upon  the  stitches  will  prevent  union  of  the  superficies,  and,  perhaps, 
of  some  of  the  deeper  essential  parts.  When  redundant  it  is  better 
to  dissect  up  the  skin  or  mucous  membrane  as  flaps,  and  unite  them 
by  superficial  stitches,  for  by  their  resulting  amplitude  they  vill  add 
to  the  distensibility  of  the  structures,  and  tend  to  prevent  laceration 
under  subsequent  distension,  rather  than  to  favor  it,  as  would  be  the 
case  when  too  much  is  removed. 

Sutures. 

I  use  a  semicircular  needle  like  that  described  for  the  immediate 
perineorrhaphy,  for  the  external  stitches  (p.  195).  I  hold  the  ends  of 
the  first  two  fingers  within  the  curve,  and  the  thumb  against  them 
from  without,  and  carry  the  point  completely  around  through  both 
sides  before  drawing  it  through.     For  the  vaginal  and  vulval  stitches 

Fig.  158.  Fig.  159. 


Fig.  158. — Silver  Suture  Bent  so  as  to  lie  Flat  upon  the  Skin. 

Fig.  159.— Silver  Suture  Twisted  Without  being  properly  Bent  at  the  point  of  Emergence  from 
the  Skin,  showing  the  harmful  pressure  upon  the  edges.  The  wound  above  the  dotted  lines 
usually  suppurates. 

a  smaller  curved  needle  used  with  a  needle-holder  is  sometimes  more 
convenient.  Needles  mounted  on  a  handle  are  not  to  be  recommended 
as  they  make  too  large  a  puncture,  are  liable  to  break,  require  thread- 
ing after  being  passed,  and  possess  no  advantage  over  a  good  needle- 
holder. 

It  is  better  to  introduce  the  needle  at  or  near  the  edge  of  the  wound 
or  flap,  and  pass  it  obliquely  deep  into  the  tissue,  in  order  to  grasp 
deeply,  and  at  the  same  time  take  a  circular  direction  when  the  sur- 
faces are  coapted  (see  Fig.  126).  The  deeper  the  wound  the  nearer 
the  edge  should  the  needle  be  entered.  Silver  sutures  (see  Chapter 
IX.  "  Urinary  Fistula,")  may,  however,  be  made  to  include  a  liberal 
portion  of  the  skin,  for  when  twisted  they  can  be  bent  at  right  angles 
at  the  points  of  emergence  from  the  skin  so  as  to  lie  flat  upon  the 
surface.  (Fig.  158  shows  the  silver  stitches  properly  twisted,  Fig.  159 
improperly.) 

Deep  stitches  should  only  be  drawn  tight  enough  to  bring  the 
surfaces  together,  as  the  subsequent  inflammation  will  tighten  them 
still  more. 


THE    QUILLED    SUTUEE. 


219 


For  the  rectal  stitches  catgut  should  nearly  always  be  used.  For 
the  deep  vaginal  stitches  silkworm  gut  or  silver  are  preferable,  that 
they  may  be  left  in  place  as  long  as  desirable.  For  the  vulva,  silk- 
worm gut  or  silk  are  best,  although  catgut  will  do  for  vulval  flaps. 
For  the  external  stitches  waxed  silk  or  silkworm  gut  are  the  best,  and 
will,  if  properly  placed,  give  as  good  results,  and  much  less  trouble, 
than  silver.  Silk  is  usually  preferable  for  the  flap  stitch,  as  it  accom- 
modates itself  better  when  tied  to  the  direction  of  the  surfaces.  Silk- 
worm gut  when  tied  draws  the  parts  into  its  circle,  and  requires  to  be 
passed  through  the  tissues  in  a  circular  direction. 

When  silver  sutures  are  used  the  twisted  ends  should  be  left  from 
two  to  three  inches  long,  and  made  to  converge  near  the  ends  to  a 
common  point,  and  then  fastened  into  a  piece  of  rubber  tubing. 

Fig.  160. 


.  Method  of  Securing  the  Twisted  Ends  of  the  Silver  Sutures  (Emmet). 

Catgut  stitches  should  be  left  to  be  absorbed.  Silkworm-gut  may 
be  left  in  as  long  as  desirable,  and  will  not  ulcerate,  nor  be  absorbed 
for  a  long  time.  Silk  absorbs  secretions,  and  may  commence  to 
ulcerate  in  from  five  to  six  days,  and  should  be  removed  as  soon 
as  an  increasing  redness  or  commencing  ulceration  about  the  stitch  is 
noticed.  Silver,  if  properly  placed,  may  be  left  for  a  week  or  more, 
but  is  liable  to  ulcerate,  and  require  removal  in  five  or  six  days  when 
there  is  much  traction  upon  it,  or  when  it  is  twisted  too  tight. 


The  Quilled  Suture. 

Although  somewhat  antiquated  the  quilled  suture  is  one  of  the 
most  useful  and  rational  ones.    It  brings  the  deeper  parts  in  apposition 


220 


LACEEATION    OF   THE    PERIXEUM    AXD    PELVIC    FLOOR. 


without  compressing  or  depressing  the  superficial  edges.  It  is  called 
for  when  there  has  been  sloughing  after  labor,  or  removal  of  tissue 
by  previous  unsuccessful  operation,  producing  great  lateral  traction. 
The  suture  (Fig.  161)  consists  of  a  double  thread  passed  through  the 
skin  about  half  an  inch  from  the  edge  of  the  wound  straight  down 
into  the  deeper  tissues,  out  over  a  small  space  at  the  bottom,  and  through 
the  other  side  so  as  to  emerge  opposite  the  first  point  of  introduction. 
Two,  sometimes  three,  such  double  threads  are  passed  and  secured  by- 
slipping  a  quill  or  flexible  bougie,  or  the  like,  into  the  loops  of  the 


Fig.  161. 


6 


B 


Quilled  Sutures,  Tied  (Zweifel). 

double  ends  on  the  side  of  introduction,  and  after  drawing  them 
tightly  so  as  to  grasp  the  quill,  tying  them  over  a  quill  on  the  opposite 
side.  Before  being  tied  the  sutures  must  be  drawn  tight  enough  to 
approximate  the  bottom  of  the  w^ound.  The  cutaneous  edges  are  then 
united  by  several  superficial  stitches. 

The  traction  upon  the  quilled  sutures  is  often  very  great,  and  in  a 
few  days  causes  some  ulceration  upon  the  skin  under  the  quills.  As 
soon  as  this  occurs,  after  the  fourth  day,  they  must  be  taken  out. 
The  superficial  ones  should  be  left  a  little  longer.  Many  prefer  to 
secure  each  suture  to  a  button  i3late  on  either  side. 


INCLSION    OF   SPHINCTER   ANI — AFTER-TREATMENT.  221 

Incision  of  Sphincter  Ani. 

As  the  great  barrier  to  success  in  the  operations  for  complete  lacera- 
tions seems  to  be  the  traction  of  the  sphincter  ani,  one  or  two  incisions 
(open  or  subcutaneous)  through  the  posterior  part  of  the  muscle  are 
sometimes  made  over  it.  This  effectually  relieves  the  traction,  and  is 
a  desirable  safeguard  in  very  old  lacerations  ;  but  is  not  necessary  in 
lacerations  of  only  a  few  months  standing,  provided  the  entire  thick- 
ness of  the  sphincter  has  been  coapted  by  the  two  lower  external 
sutures.  It  is,  however,  sufficient  in  any  case  to  cut  about  two-thirds 
through  the  muscle,  and  thus  gain  a  partial  relaxation.  Or  the  in- 
ternal fibres  may  be  relaxed  by  an  incision  half-way  through  the 
muscles  posteriorly  on  one  side,  and  the  external  fibres  also  relaxed 
by  a  subcutaneous  incision  on  the  other  side  involving  only  the  ex- 
ternal fibres. 

After-Treatment. 

When  the  rectum  is  not  involved  the  patient  is  put  to  bed  for  eight 
days,  and  then  kept  quiet  for  another  week,  A  napkin  should  be 
pinned  about  the  knees  of  restless  patients  so  that  they  cannot  be 
separated  farther  than  twelve  inches.  The  wound  is  kept  smeared 
with  any  bland  ointment  to  protect  it.  A  piece  of  lint  or  iodoform 
gauze  may  also  be  laid  over  it  to  absorb  the  discharges. 

It  is  well,  but  not  absolutely  necessary,  to  draAV  the  urine  with  a 
catheter  for  the  first  two  or  three  days,  after  which  a  flat  bed-pan  may 
be  used.  After  each  time  that  the  urine  is  drawn  or  passed  the  nurse 
should  slightly  separate  the  upper  ends  of  the  labia,  so  as  to  barely 
expose  the  edges  of  the  wound,  and  squeeze  warm  water  over  the  vulva 
and  perineum,  for  the  purpose  of  removing  all  traces  of  urine  and 
vaginal  discharge. 

When  no  inclination  is  felt  to  evacuate  the  bowels,  they  need  not 
be  disturbed  for  four  or  five  days.  A  dose  of  castor  oil  or  a  saline  should 
then  be  given,  and  an  evacuation  secured  every  two  days  thereafter. 
The  parts  must,  of  course,  be  thoroughly  cleansed  after  each  passage. 
Until  the  bowels  move  the  diet  should  be  mostly  liquid. 

The  parts  must  be  inspected  every  day  or  two  after  the  third  day, 
and  if  any  odor  or  discharge  of  pus  be  noticed  vaginal  douches  be 
used.  One  or  two  per  cent,  solutions  of  carbolic  acid  in  water  twice 
or  three  times  a  day  according  to  the  amount  of  suppuration,  will  be 
found  very  effective.  If  the  parts  are  found  healthy  I  usually  order  a 
douche  of  plain  warm  water  twice  a  day  after  the  third  or  fourth  day, 
and  direct  the  patient  to  make  use  of  that  opportunity  for  urinating. 

When  the  sphincter  has  been  lacerated  and  the  rectum  opened  the 
patient  should  remain  longer  in  bed  and  subsist  mostly  on  fluids  for 
a  week  at  least.     Milk  on  account  of  its  tendency  to  produce  curdy 


222         LACERATIOX    OF   THE    PERIXEUM   AND    PELVIC    FLOOR. 

stools  should  be  used  sj^aringly.  Great  pains  should  be  taken  to  pre- 
vent a  movement  of  the  bowels  for  the  first  three  or  four  days,  for  be- 
fore that,  fluid  f£eces  are  liable  to  invade  the  edges  of  the  wound  and 
prevent  primary  union.  If  hard  lumps  come  down  into  the  rectum 
while  the  bowels  are  being  moved  they  must  be  mashed  against  the 
sacrum  by  the  finger  introduced  into  the  rectum.  AVhen  the  colon 
has  previously  been  completely  emptied,  as  already  directed,  the 
bowels  may  just  as  well  be  kept  quiet  for  eight  or  nine  days,  when  the 
introduction  of  the  finger  to  feel  for  lumps  will  be  safe. 

Undue  swelling  and  painfulness  about  the  perineum  may  excep- 
tionally require  the  local  application  of  ice-bags. 

The  patient  should  be  kept  in  bed  from  ten  days  to  three  weeks 
according  to  the  extent  of  the  laceration. 


CHAPTER  VIII. 

DISEASES    OF    THE    BLADDEE. 

Paralysis  of  the  Bladder. 

Paralysis  of  the  female  bladder  is  often  an  accompaniment  of 
hemiplegia  or  paraplegia  from  cerebral  or  spinal  affections,  and  be- 
comes a  part  of  these  more  extensive  affections.  From  my  own  ob- 
servation, however,  I  should  say  that  in  women,  retention  of  urine  in 
such  cases  is  not  so  uniformly  a  troublesome  symptom  as  it  is  in  the 
paralysis  of  men. 

Women  have  paralysis  of  the  bladder  more  frequently  associated 
with  hysteria,  probably,  than  with  cerebro-spinal  disease,  which  con- 
dition, of  course,  is  a  part  of  the  hysterical  affection. 

Again,  it  may  arise  from  reflex  causes.  I  once  saw  paralysis  of  the 
bladder  caused  by  the  presence  of  a  tapeworm. 

Still  more  frequent  is  the  paralysis  succeeding  tedious,  difficult,  or 
instrumental  labor,  as  the  result  of  injury  to  the  muscular  structure 
of  the  bladder  from  long-continued  direct  pressure  on  the  organ,  or 
to  the  nerves  supplying  the  bladder,  by  the  use  of  instruments,  or  by 
long-continued  pressure  of  the  head.  The  inflammation  succeeding 
labor  may  also  affect  the  organ  sufficiently  to  cause  paralysis. 

Prognosis. 

Usually  paralysis  occurring  as  the  result  of  labor  is  temporary,  and 
amenable  to  judicious  treatment,  if  it  does  not  spontaneously  subside. 
Unfortunately,  however,  this  is  not  always  so.  I  know  of  two  in- 
stances that  have  resisted  such  management  as  could  be  devised  for 
them  by  several  able  practitioners,  one  for  twelve  years  and  the  other 
for  seven  years.  Both  of  these  patients  use  the  catheter  for  themselves 
when  there  is  an  accumulation  of  urine. 

Symptoms. 

The  main  symptoms  indicating  paralysis  of  the  bladder  are  inability 
to  pass  urine  and  distension  of  the  organ.  The  retention  is  not  always 
absolute ;  in  some  instances  the  urine  dribbles  away  constantly  by 
drops,  keeping  the  clothing  wet. 

The  patient  and  inexperienced  friends  often  believe  that  there  is 
incontinence  instead  of  retention,  on  account  of  this  continued  dis- 
charge.- In  other  cases,  however,  where  the  paralysis  is  more  pro- 
found, there  is  no  discharge.     The  distension  sometimes  becomes  very 


22-i  DISEASES    OF    THE    BLADDEE. 

great,  extending  beyond  the  umbilicus  half  way  to  the  ensiform  car- 
tilage. 

Retention  of  the  urine  sometimes  occurs  as  the  etfect  of  inflamma- 
tion of  the  urethra.  This  canal  becomes  so  sensitive  to  the  passage 
of  that  fluid  through  it,  that  the  sphincter  closes  spasmodically  when 
there  is  any  attempt  to  urinate. 

Diagnosis. 

Paralysis  of  the  bladder  may  be  diagnosticated  without  much  diffi- 
culty generally.  The  patient  is  conscious  of  inability  to  exert  suffi- 
cient power  to  expel  the  urine,  but  often  has  no  sensitiveness  or  pain 
upon  voiding  it. 

The  hysterical  form  is  usually  attended  with  other  symptoms  of 
this  affection,  appears  quickly  and  disappears  as  suddenly,  while  the 
urine  is  copious  and  clear.  There  is  something  in  the  manner  of  the 
patient  which  will  often  lead  the  inexperienced  to  think  that  she  de- 
su'es  to  have  it  drawn  by  the  catheter. 

Cases  resulting  from  injury  at  the  time  of  labor  may  be  traced  to 
that  event. 

Treatment. 

Treatment  for  temporary  relief  will  consist  mainly  in  the  use  of  the 
catheter.  I  think  this  instrument  is  generally  used  at  too  long  inter- 
vals, especially  in  the  form  arising  from  injury  during  labor.  I  have 
often  known  cases  of  this  kind  to  be  neglected  for  twenty-four  hours 
at  a  time. 

As  a  general  rule,  to  pass  the  catheter  ever}^  six  hours  is  not  too 
frequent.  The  muscular  fibres  should  not  be  stretched  by  a  consider- 
able and  prolonged  distension,  as  that  will  prevent  them  from  recover- 
ing their  tone.  And  if  the  organ  is  kept  well  emptied,  there  is  no 
danger  of  decomposition  of  the  urine  and  the  consequent  irritation 
and  inflammation  of  the  mucous  membrane.  An  intelligent  nurse 
can  be  taught  to  perform  catheterism  very  easily,  and  may  be  trusted 
to  do  so  according  to  instructions  as  to  time  and  other  circumstances. 

If  the  paralysis  is  connected  with  any  general  condition,  as  hysteria, 
this  latter  should  be  attended  to  by  general  treatment. 

If  the  paralysis  is  general,  the  vesical  affection  will  share  in  the 
general  treatment  of  that  affection. 

The  general  health  is  usually  impaired  even  when  the  paralysis  is 
purely  local  in  its  origin,  and  often  it  is  one  of  prostration.  "When 
this  is  the  case,  generous  diet,  exposure  to,  and  when  practicable, 
exercise  in  the  open  air,  with  tonics  and  proper  alteratives,  will  be 
indicated.  Strychnia,  quinine,  and  iron,  separately  or  combined,  will 
be  useful  remedies.  The  strychnia  is  particularly  indicated  as  giving 
tone  especially  to  muscular  fibre  and  hence  operating  favorably  on 


HYPERESTHESIA  OF  THE  BLADDER  AND  URETHRA.     225 

the  debilitated  tissue  of  the  bladder.  Phosphoric  acid  is  also  usually 
an  excellent  tonic  in  such  cases.  The  bowels  should  be  kept  in  a 
soluble  condition  by  the  gentlest  of  laxatives. 

When  there  is  evidence  of  inflammation  of  any  of  the  pelvic  viscera, 
we  should  remove  it  by  the  proper  means  before  resorting  to  direct 
remedies  to  remove  the  paralysis.  After  all  inflammation  is  removed, 
we  may  employ  electricity  to  stimulate  the  muscular  fibres  to  contrac- 
tion. An  electro-magnetic  current  may  be  passed  through  the  bladder 
in  various  directions,  so  as  to  stimulate  all  the  fibres  successively, 
applying  the  positive  pole  over  the  spine  and  across  the  posterior  part 
of  the  loins,  iliac  and  sacral  regions,  while  the  negative  may  be  brought 
in  contact  with  the  symphysis,  perineum,  and  labia,  and  by  means 
of  a  catheter  introduced  into  the  urethra,  passed  slowly  into  the 
bladder.  The  whole  of  this  faradization  should  not  last  more  than 
five  minutes  at  first,  and  should  be  repeated  once  a  day.  After  the 
patient  has  had  three  or  four  sittings,  the  force  of  the  current  and  the 
duration  may  be  gradually  increased.  It  is  sometimes  ver}^  beneficial 
to  pass  the  current  from  the  anterior  part  of  the  abdomen  into  a 
metallic  speculum  in  the  vagina.  I  have  seen  many  cases  yield  to 
this  plan  of  treatment.  A  remedy  that  seems  to  have  a  very  ready 
efiect,  and  to  which  I  think  I  may  attribute  a  cure  in  some  cases,  is  the 
secale  cornutum.  The  fluid  extract  of  ergot  administered  in  decided 
doses,  once  in  a  half  hour  for  four  or  five  doses,  when  the  bladder  is 
somewhat  distended,  often  acts  very  promptly.  A  good  way  to  admin- 
ister the  ergot  is  to  induce  decided  ergotism,  or  to  give  enough  for  that 
purpose  every  day  and  suspend  the  remedy  in  the  intervals.  I  have 
been  in  the  habit,  also,  of  administering  biborate  of  soda  in  doses  of 
twenty  grains  four  times  a  day  with  benefit.  It  is  probable  that  all 
the  substances  that  induce  uterine  contraction  will  influence  the 
bladder  similarly. 

Hemorrhage  from  the  Bladder. 

A  bloody  discharge  from  the  female  bladder,  not  the  result  of  organic 
lesion  of  that  viscus,  is  far  from  infrequent.  It  occurs  more  frequently, 
judging  from  my  own  observation,  about  the  time  of  the  menstrual 
period  and  in  persons  whose  flow  is  small  in  quantity.  It  is  seldom, 
if  ever,  sufficiently  copious  to  cause  alarm,  and  the  treatment  of  it  may 
be  trusted  to  the  remedial  measures  required  for  the  accomj^anying 
disease,  whatever  it  may  be. 

Hypersesthesia  of  the  Bladder  and  Urethra — IrritaMe  Bladder  and  Urethra. 

An  irritable  condition  of  the  bladder  and  urethra  is  a  very  common 
occurrence  among  women,  and  is  sometimes  very  distressing  and  per- 
sistent. The  symptoms  are  frequent  desire  to  urinate,  with  the  dis- 
charge of  but  a  small  quantity  at  each  time,  vesical  tenesmus,  heat 

15 


226  DISEASES    OF   THE    BLADDER. 

and  weight,  together  with  a  scalding  sensation  at  the  time  of  passing 
the  water.  This  irritable  condition  may  sometimes  last,  with  varying 
severity,  for  weeks  and  even  months  without  being  attended  with  any 
considerable  amount  of  apparent  disease  in  the  parts. 

Causes. 

It  is  many  times  associated  with  inflammation  and  hypereesthesia 
of  the  vagina,  with  chronic  metritis  in  some  of  its  various  forms, 
with  displacements  of  the  uterus,  and  irritation  of  the  rectum  from 
hemorrhoids,  fissures,  etc.  But  sometimes  we  meet  with  it  when  we 
can  assign  no  cause  whatever. 

Treatment. 

When  it  is  possible  to  discover  and  remove  the  cause,  that,  of  course, 
should  be  done.  It  will  often  subside  under  the  treatment  for  the 
vaginitis  that  often  attends  it,  or  that  made  use  of  to  remove  ulceration 
and  inflammation  of  the  cervix  uteri.  So,  also,  when  displacements 
are  corrected.  When  we  cannot  trace  it  to  an}^  of  these  causes,  the 
urine  should  be  examined,  and  if  found  of  strong  acid  reaction  this 
condition  should  be  corrected.  This  irritable  condition  of  the  bladder 
is  quite  common  in  women  advanced  in  age,  as  the  result  of  a  highly 
acid  state  of  the  urine,  and  may  generally  be  relieved  by  the  alkalies, 
of  which  the  preparations  of  potassa  are  probably  the  best.  The  liquor 
potassse,  in  doses  of  from  ten  to  fifteen  drops,  before  and  after  eating, 
is  often  very  efficacious.  In  young  women  of  sedentary  habits  the 
vegetable  acids  will  often  imjDrove  the  condition  of  the  urine  and 
render  it  less  irritating.  In  either  case  the  bitters  may  generally  be 
given  with  advantage.  There  are  some  medicines  that  seem  to  have  a 
peculiar  influence  upon  the  urinary  organs,  and  may  often  be  given  in 
cases  of  this  kind  with  great  benefit.  Among  such  are  pareira  brava, 
buchu,  and  uva  ursi.  The  fluid  extracts  of  these  medicines  are  the 
most  convenient  forms  for  administration ;  but  sometimes  the  extracts 
are  not  good,  and  hence  I  have  been  in  the  habit  of  relying  more  on 
the  decoction  than  any  other  form.  I  often  combine  the  buchu  and 
uva  ursi  with,  I  think,  excellent  effect.  When  the  distress  is  consider- 
able we  may  very  properly  use  belladonna  suppositories,  per  vaginam, 
at  night.  A  half  grain  of  the  extract  in  cocoa  butter,  the  same  amount 
of  sulphate  of  morphia,  will  often  quiet  the  patient  and  enable  her  to 
rest,  when  otherwise  she  would  be  annoyed  by  frequent  desire  to 
urinate.  Vaginal  injections  of  tepid  or  warm  water  often  relieve  the 
suftering,  so  do  hip-baths  and  water  compresses  over  the  lower  part  of 
the  abdomen.  The  daily  introduction  of  a  number  12  steel  sound 
will  often  cure  very  obstinate  cases. 


CHEONIC   INFLAMMATION    OF   THE    BLADDER.  227 

Chronic  Inflammation  of  the  Bladder. 

Although  women  are  subject  to  acute  cystitis,— probably  not  as  often 
as  men, — there  is  nothing  in  the  course  of  the  disease,  or  the  treatment, 
that  requires  special  consideration  in  a  work  of  this  kind.  The  chronic 
form,  however,  so  far  as  I  can  judge  from  my  own  observation,  is  more 
frequent  in  women  than  in  men,  and  its  course  and  treatment  are 
both,  in  some  respects,  quite  different,  so  that  I  am  induced  to  give  it 
distinct  consideration  here.  It  often  complicates  the  various  diseases 
of  the  uterus  and  vagina,  and  the  displacement  of  these  organs.  It  is 
also  caused  by  foreign  bodies  in  the  bladder,  as  calculi,  and  substances 
introduced  from  without,  and  by  chronic  cellulitis. 

Nature  and  Progress. 

In  the  beginning  the  inflammation  in  most  cases  is  confined  to  the 
mucous  membrane  ;  after  awhile  the  muscular  tissue  becomes  affected. 
In  the  early  stage  of  the  affection,  while  the  inflammation  is  confined 
to  the  mucous  membrane,  the  bladder  empties  itself  completely  but 
with  great  pain.  As  soon  as  the  muscular  structure  is  injured  by  the 
processes  of  inflammation,  especially  by  the  deposition  of  fibrin,  the 
walls  become  thickened  and  uneven,  contraction  is  imperfect,  and 
hence  the  urine  is  retained,  at  first  in  small  quantities  and  afterwards 
in  larger  ;  decomposition  of  this  fluid  takes  place,  the  inflammation  is 
aggravated,  and  ulceration  follows  in  many  instances ;  the  patient  some- 
times dies  from  protracted  suffering,  or  life  is  suddenly  terminated  by 
the  ulceration  perforating  the  wall  entirely  and  causing  fatal  inflam- 
mation in  the  peritoneum  or  cellular  tissue.  Occasionally  the  inflam- 
mation spreads  to  the  ureters,  and  through  them  to  the  kidneys.  The 
urethra  may  or  may  not  be  involved  in  the  inflammation.  Generally 
the  cystic  portion  is  more  or  less  affected,  and  the  ulceration  in  this 
direction  will,  in  extremely  rare  instances,  perforate  the  vesico-vaginal 
septum  and  thus  cause  fistula.  The  inflammation  from  foreign  bodies 
contained  in  the  bladder  would  be  more  likely  to  effect  this  condition, 
than  inflammation  arising  from  any  other  cause. 

Symptoms. 

Dysuria,  if  not  the  most  frequent  symptom,  is  certainly  one  of  the 
most  frequent.  The  presence  of  even  a  small  quantity  of  urine  in 
contact  with  the  inflamed  mucous  membrane  irritates  and  causes  a 
desire  to  evacuate  it.  There  is  also  heat,  a  sense  of  weight  or  drag- 
ging in  the  loins,  the  region  of  the  bladder,  and  in  the  pelvis,  with  a 
great  amount  of  general  suffering;  constipation,  indigestion,  some- 
times nausea,  and  various  nervous  symptoms  being  among  the  general 
symptoms. 

The  urgency  of  the  symptoms  will  depend,  iu;  a  great  measure,. 


228  DISEASES    OF   THE   BLADDER. 

upon  the  amount  of  inflammation,  but  somewhat  also  on  the  consti- 
tutional peculiarities  of  the  j^atient.  The  frequency  of  the  discharge 
becomes  very  great,  as  there  is  constant  pain  and  desire  to  urinate  on 
account  of  the  irritating  character  of  the  urine.  With  the  urine  is 
discharged  a  large  amount  of  mucus,  and  as  the  disease  advances 
pus  and  blood-globules  are  found  in  the  urinary  sediment.  The  ap- 
pearance of  the  sediment  is  almost  characteristic.  It  occupies  the 
bottom  of  the  vessel,  is  pellucid,  tinged  with  yellow  if  there  is  pus  in 
it,  or  red  if  it  contains  blood-corpuscles,  and  when  poured  out  either 
comes  in  a  jellj^-like  mass  or  in  long  strings  of  mucus  that  may  be 
drawn  out  to  great  lengths.  At  the  bottom  of  the  sediment  are  usually 
found  an  abundance  of  the  phosphatic  salts.  As  the  disease  advances, 
the  odor  of  the  urine  becomes  highly  ammoniacal  and  not  unfre- 
quently  fetid.     Generally  the  odor  is  quite  unnatural. 

Diagnosis. 

The  diagnosis  is  not  difficult.  The  sediment  of  the  urine,  under  the 
microscope,  will  show  the  presence  of  pus-globules  in  grave  cases,  and 
sometimes  blood-globules.  When  pressed  upon  above  the  pubis  the 
bladder  will  be  found  tender.  This  tenderness  will  be  more  evident 
upon  introducing  two  fingers  into  the  vagina  and  elevating  the  bladder 
upon  them,  while  pressure  is  made  above  the  pubis.  The  bladder 
may  be  thus  included  between  the  two  hands.  The  tenacious  ropy 
sediment,  the  pus  and  blood-globules,  especially  the  former,  and  the 
tenderness  of  the  bladder  upon  bimanual  pressure  are  the  main  diag- 
nostic symptoms. 

Prognosis. 

Chronic  inflammation  of  the  bladder  is  an  obstinate  disease,  and  is 
very  difficult  of  cure  ;  yet  it  probably  does  not  often  prove  fatal. 

Treatment. 

The  complicating  conditions — as  the  disease  is  associated  with 
others  in  the  majority  of  instances — should  be  attended  to  Avith  great 
diligence.  The  pelvic  viscera  are  so  near  each  other  that  inflammation 
seldom  exists  in  one  for  a  great  length  of  time  without  spreading  to 
others.  I  believe  this  affection  is  often  the  result  of  extension  from 
the  vagina  or  uterus,  and  in  many  instances  it  arises  from  pelvic  peri- 
tonitis and  cellulitis.  Many  of  the  remedies  used  for  the  cure  of  one 
of  these  affections  will  benefit  the  others  also.  The  use  of  the  hip-bath 
once  or  twice  daily,  copious  warm-water  injections  as  often,  poultices, 
compresses,  iodine  ointment,  vaginal  suppositories, — of  anodynes 
especially, — will  all  have  the  effect  of  relieving  intra-pelvic  hypersemia 
and  hyperesthesia.  Counter-irritants  of  a  decided  character  may  fre- 
quently be  made  of  great  service.     One  or  twosetons  introduced  just 


CHRONIC    INFLAMMATION    OF   THE    BLADDER.  229 

above  Poupart's  ligament,  in  one  or  both  sides,  are  very  effective  means 
of  making  it.  They  may  be  controlled  better  than  blisters  or  eruptive  ir- 
ritants. We  have  a  number  of  articles  in  the  materia  medica  that  exert 
a  curative  influence  by  contact  with  the  mucous  membrane  of  the 
bladder.  They  are  eliminated  from  the  blood  by  the  kidneys,  and 
held  in  solution  or  suspension  in  the  urine,  thus  becoming  applied  to 
the  diseased  surface.  Probably  chief  among  these  is  pareira  brava.  I 
think  the  best  way  to  administer  this  is  in  decoction,  although  the 
fluid  extract,  lohen  properly  made,  is  a  good  form;  buchu,  uva  ursi,  and 
juniper  are  also  very  useful.  I  think  more  good,  in  most  cases,  results 
from  the  use  of  buchu  and  uva  ursi  together  than  from  either  alone. 
Iodide  of  potassium,  permanganate  of  potash,  and  some  other  salts  of 
this  alkali,  the  acetates  and  nitrates,  for  instance,  exert  an  excellent 
alterative  eflFect  upon  the  mucous  membrane  of  the  bladder.  The  tere- 
binthinates  may  be  used  with  great  advantage  in  the  milder  forms  of 
this  inflammation.  Perhaps  balsam  copaiba  is  the  most  uniformly 
beneficial  of  this  class  of  remedies.  Cubebs  may  also  be  employed 
occasionally  with  good  efiect.     The  above  treatment  is  applicable  and 


Fig.  162. 


Skene's  Double  Perforated  Catheter. 


often  suflicient  in  the  earlier  stages  and  milder  forms  of  chronic  in- 
flammation of  the  bladder  ;  but  after  contraction  of  the  organ  is  im- 
paired by  the  extension  of  the  inflammation  to  the  muscular  structure, 
surgical  treatment  becomes  indispensable  to  a  successful  issue.  It  is 
necessary  that  the  acrid  urine  be  completely  removed  from  the  bladder 
before  it  enters  into  chemical  decomposition,  which  it  does  very  quickly. 
At  the  same  time  the  direct  application  of  medicine  to  the  inner  surface 
can  and  ought  to  be  made  while  alterative  and  tonic  general  treatment 
is  instituted  to  overcome  interstitial  inflammation  and  remove  the 
fibrinous  deposit.  Often  we  may  accomplish  the  processes  of  emptying 
the  bladder  and  applying  the  medicinal  agents  by  means  of  the  double 
catheter.  To  insure  the  efficacy  of  these  measures  the  organ  may  be 
washed  out  by  warm  water  thrown  through  the  catheter  by  a  David- 
son syringe,  and  after  all  the  urine  is  Avashecl  out  the  medicinal  solu- 
tion may  be  introduced,  and  allowed  to  remain  until  its  action  is 
accomplished.  When  there  is  much  pain  a  quarter  or  half  grain  of 
morphia  once  in  twenty-four  hours  will  secure  immunity  from  suffer- 
ing. We  may  combine  with  the  morphia  a  solution  of  iodide  of  potas- 
sium, permanganate  of  potash,  tannic  acid,  acetate  of  lead,  or  other 
astringent :  or  we  administer  in  the  same  way  a  small  amount  of  an 


230  DISEASES    OF   THE    BLADDER. 

emulsion  of  balsam  copaiba.  Nitrate  of  silver  will  also  frequently 
cause  a  better  condition  of  the  inflamed  surface.  The  ingenuity  and 
experience  of  the  practitioner  will  generally  suggest  remedies  of  the 
above  character  best  suited  to  the  particular  case.  Due  caution  must 
be  observed  not  to  use  the  remedies  in  too  concentrated  strength  until 
the  tolerance  of  the  inflamed  surface  is  ascertained.  These  medica- 
tions should  be  applied  once  a  day  at  first,  and  afterwards  as  often  as 
may  be  required.  It  should  be  borne  in  mind  that  the  mucous  mem- 
brane of  the  bladder  is  very  sensitive  and  that  medicines  are  readily 
absorbed  by  it.  In  connection  with  this  surgical  treatment  ergot  and 
strychnia  may  be  given  to  insure  tone  in  the  muscular  structure. 
They  ought  not  to  be  administered,  however,  until  the  activity  of  the 
inflammation  has  somewhat  subsided.  Dr.  J.  L.  Papin,  of  St.  Louis, 
has  practiced  a  plan  for  relieving  the  irritable  and  inflamed  condition 
of  the  bladder  by  dilating  the  urethra  so  as  to  paralyze  the  contractile 
fibres  and  leave  the  canal  patulous,  thus  allowing  the  urine  to  pass  out 
as  fast  as  secreted,  instead  of  permitting  it  to  remain  in  the  bladder  to 
irritate  it.  The  treatment  is  described  in  a  paper  written  by  Dr.  M. 
Yarnall  for  the  January  (1872)  number  of  the  Medical  Archives,  pub- 
lished in  that  city.  The  operation  is  thus  described :  The  urethra  is 
dilated  "  with  a  long  pair  of  dressing-forceps  to  such  an  extent  as  to 
produce  a  temporary  incontinence  of  urine,  by  rupturing  a  few  of  the 
fibres  of  the  sphincter  of  the  bladder,  and  repeating  the  operation  when 
necessary,  at  intervals  of  a  week  or  more,  until  the  patient  is  completely 
relieved."  Twenty  cases  are  mentioned  as  having  been  treated  in  this 
way,  and  the  report  is  :  "  In  nearly  every  instance  the  relief  afforded 
is  almost  immediate ;  but  in  the  course  of  a  few  days  the  irritability 
of  the  bladder  usually  returns,  when  the  operation  has  to  be  repeated, 
and,  if  necessary,  again  repeated  until  a  cure  is  accomplished."  In 
one  case  the  operation  was  repeated  five  times,  in  some  others  three 
and  four  times.  The  experience  of  Dr.  Papin  is  such  that  he  does  not 
fear  incontinence  of  urine.  "  The  operation  being  at  first  very  painful, 
it  will  usually  be  found  necessary  in  performing  it  the  first  time  to 
place  the  patient  under  the  influence  of  an  anaesthetic ;  but  its  subse- 
quent performance  being  much  less  severe,  as  a  rule  the  anaesthetic 
will  not  be  necessary,  unless  the  patient  be  of  a  very  nervous  tempera- 
ment." This  dilatation  will  much  facilitate  the  use  of  medicated  in- 
jections and  preclude  the  need  of  a  double  catheter. 

This  operation  is  very  simple,  and,  according  to  the  report  of  Dr. 
Yarnall,  very  efficacious. 

I  have  practiced  dilatation  of  the  urethra  quite  frequently  with  re- 
sults not  inferior  to  those  here  reported. 

I  invariably  use  the  finger  in  place  of  any  other  instrument.  One  of 
the  dangers  of  dilatation  of  the  urethra  is  laceration  of  the  circular 
fibres  of  that  canal,  and  consequent  incontinence  of  urine.     I  have  not 


STONE   IN    THE    BLADDER.  231 

met  with  an  instance  of  this  kind,  nor  have  I  seen  any  other  serious 
consequences  follow  dilatation.  The  finger  may  be  passed  through  so 
slowly  that  the  fibres  will  stretch,  and  endowed  as  it  is  with  a  delicate 
sense  of  touch,  it  easily  recognizes  the  unyielding  tension  which  indi- 
cates care.  In  this  it  would  be  entirely  preferable  to  any  kind  of  in- 
strument. Compressed  sponge  or  laminated  tents  dilate  so  slowly  and 
remain  in  contact  with  the  canal  so  long  as  to  induce  inflammation 
and  softening  of  the  muscular  fibres,  and  instead  of  preparing  the  way 
for  further  safe  dilatation  would  predispose  to  laceration. 

Dr.  Goodman,  of  Louisville,  uses  a  catheter  with  a  small  bulb  on 
the  vesical  extremity  of  it,  with  which  he  secures  an  empty  state  of  the 
bladder.     (Fig.  105). 

Dr.  Sims's  well-known  practice  of  incising  the  vesico- vaginal  septum 
has  for  its  support  the  favorable  report  of  its  distinguished  originator 
and  Dr.  Emmet,  his  successor  in  the  Woman's  Hospital  of  New  York. 
The  latter  gentleman  has  written,  and  read  before  the  Academy  of 
Sciences  of  New  York  City,  quite  an  elaborate  paper  advocating  the 
propriety  of  making  a  fistula  through  which  the  urine  will  pass  without 
accumulating  in  the  bladder,  and  through  which  very  effective  medicinal 
application  may  be  made  to  the  inflamed  surface.  The  patient  may 
be  placed  in  the  position  advised  to  operate  for  vesico-vaginal  fistula, 
and  the  parts  exposed  by  Sims's  speculum.  The  surgeon  may  then 
pass  a  grooved  director  into  the  urethra  with  the  groove  toward  the 
,vaginal  septum,  and  cut  down  upon  the  director  until  an  opening  is 
made  large  enough  to  answer  the  purpose.  There  is  probably  more 
danger  of  having  the  opening  too  small  than  of  getting  it  too  large,  as 
the  parts  contract  and  have  a  strong  tendency  to  close  up  before  the 
cure  is  effected.  The  opening  should  be  about  an  inch  in  length. 
With  this  free  communication  with  the  interior  of  the  bladder  the 
medication  may  be  complete.  Tincture  of  iodine,  a  solution  of  nitrate 
of  silver,  and  the  various  astringents  may  be  applied  through  the  arti- 
ficial opening.  The  injections  for  washing  out  the  bladder  can  be  used 
with  such  freedom  as  will  insure  cleanliness.  Dr.  Emmet  assures  us 
that  this  method  of  treatment  has  been  almost  uniformly  successful  in 
his  hands.  The  operation  to  cure  the  fistulous  communication  be- 
tween the  bladder  and  vagina  is  so  well  understood  and  so  generally 
successful,  that  the  surgeon  will  not  dread  the  consequences  of  this 
plan  as  it  would  have  been  dreaded  some  years  ago,  and  I  need  hardly 
say  that  the  opening  should  not  be  closed  until  the  inflammation  is 
entirely  cured.     It  often  closes  spontaneously. 

Stone  in  the  Bladder. 

Vesical  calculus  in  the  female  is  of  very  rare  occurrence,  absolutely 
and  relatively.  Of  all  the  cases  of  vesical  calculus  only  about  one  in 
twenty  is  met  with  in  the  female  sex.     This  may  be  accounted  for  by 


232  DISEASES    OF   THE    BLADDER. 

the  size,  straight  form,  and  dilatability  of  the  urethra,  and  consequent 
direct  escape  of  small  sanguineous  and  mucous  accumulations,  and 
even  sandy  concretions.  Indeed,  quite  large  stones  are  expelled 
through  the  urethral  canal,  making  their  way  out,  in  some  instances, 
in  a  few  moments  with  acute  suffering,  while  in  others  they  are  many 
hours  in  forcing  a  passage.  It  would  seem  that  these  hard  substances 
are  evacuated  more  readily  during  the  state  of  pregnancy  than  at  any 
other  time  ;  doubtless,  because  of  the  urethra  partaking  in  the  general 
increased  dilatability  of  the  genital  organs  which  precedes  labor. 

Symjotoms. 

There  are  probably  no  S3'mptoms  attendant  upon  stone  in  the  blad- 
der in  woman  but  what  are  produced  more  frequently  by  other  causes, 
hence  they  are  quite  unreliable,  and  can  be  taken  only  as  suspicious 
instead  of  diagnostic  evidence  of  its  presence.  They  are  great  and 
persistent  irritability  of  the  bladder,  severe  pain  after  voiding  the  urine, 
sudden  cessation  of  the  flow  while  there  is  yet  a  desire  to  urinate  and 
evidently  some  fluid  in  the  organ,  enlargement  or  relaxation  of  the 
urethra,  and  incontinence  of  urine.  The  urine  is  also  charged  with 
mucus,  pus,  or  blood,  or  all  three  of  these  in  greater  or  less  quantities. 
The  symptoms  will  be  more  strongly  marked  if  the  calculus  is  rough 
and  jagged  in  shape,  and  less  so  if  the  surface  is  smooth  and  even. 
All  these  symptoms  are  not  present  in  an}^  given  case,  but  some  of 
them  are  certain  to  be  prominent  and  very  distressing. 

Diagnosis. 

The  only  way  to  positively  determine  the  diagnosis  is  by  physical 
examination  of  the  cavit}"  of  the  bladder.  This  is  done  b}'  means  of 
the  fingers  and  the  sound.  If  two  fingers  be  passed  deeply  into  the 
vagina,  as  far  as  the  cervix  uteri,  the  most  dependent  part  of  the 
bladder  may  be  pressed  strongly  up  against  the  internal  face  of  the 
pelvis,  or  lower  portion  of  the  anterior  abdominal  wall.  If  this  latter 
be  pressed  well  down  into  the  pelvis  with  the  other  hand,  while  the 
fingers  are  still  in  the  vagina,  careful  manipulation  will  scarcely  fail 
to  distinguish  a  calculus  of  moderate  size.  When  the  bladder  is  full 
of  water,  if  the  calculus  is  large,  it  may  be  raised,  and  its  presence 
pretty  conclusively  determined  by  ballottement.  The  stone  is  felt,  how- 
ever, more  distinctly  through  the  urethra  by  the  sound,  used  the  same 
as  in  the  male.  The  operation  may  be  facilitated  by  the  fingers  in  the 
vagina  moving  the  stone  around.  The  same  difficulties  in  making  a 
perfect  diagnosis  are  met  with,  as  in  the  male,  if  the  stone  be  encysted 
or  adherent  to  the  upper  or  anterior  wall  of  the  bladder;  but  if  the 
instrument  is  sufficiently  curved  and  moved  about  in  various  directions 
it  will  be  detected,  and  its  position  and  size  ascertained  with  more 
precision  and  certainty  than  in  the  male. 


STONE   IN   THE   BLADDER.  233 


Treatment. 


The  only  means  of  relief  available  is  the  entire  removal  of  the 
calculus.  This  may  be  done  by  dilating  the  urethra,  and  extracting 
through  it ;  by  lithotomy  or  lithotrity.  All  these  operations  are  less 
hazardous  in  the  female  than  in  the  male,  in  fact,  we  scarcely  take  the 
subject  of  danger  to  life  into  consideration  in  operating  for  stone  on  a 
woman  ;  but  one  very  great  inconvenience  likely  to  follow  dilatation 
of  the  urethra  and  lithotomy  is  incontinence  of  urine,  and  the  atten- 
tion of  recent  operators  is  turned  mainly  to  the  matter  of  avoiding 
this  most  distressing  sequel.  The  preference  is  given  by  some  surgeons 
to  lithotomy,  because  they  think  this  evil  less  frequent  after  it,  while 
for  the  same  reason  others  resort  to  dilatation  of,  and  extraction 
through,  the  urethra.  Very  few  now  practice  lithotrity  in  the  female, 
and  this  operation  is  looked  upon  as  attended  with  more  hazard  than 
either  of  the  others.  It  is  astonishing  with  what  facility  the  female 
urethra  may  be  largely  and  rapidly  dilated.  I  have  seen  it  stretched 
so  as  to  admit  the  index  finger  in  ten  minutes  without  violence  to  its 
integrity.  Where  the  stone  is  not  very  large,  not  over  half  an  inch  in 
diameter,  we  may  expect  to  succeed  by  dilatation  without  much 
damage  if  proper  caution  and  gentleness  are  used.  When  the  stone  is 
much  larger,  and  especially  if  it  is  rough,  we  should  cut. 

The  operation  of  dilatation  is  simple.  It  may  be  performed  by  the 
finger  more  readily  and  safely  as  directed  in  chronic  inflammation  of 
the  bladder.  As  soon  as  the  finger  can  be  made  to  enter  the  bladder 
freely,  other  fingers  should  be  passed  into  the  vagina  and  caused  to 
press  the  stone  forward  so  that  its  size,  shape,  consistence,  and  the 
character  of  the  surface  may  be  ascertained.  If  there  is  a  long  diameter, 
the  end  must  be  directed  to  the  urethral  opening,  and  retained  with  as 
much  security  as  may  be  until  the  forceps  are  introduced  and  the 
stone  seized.  Traction  should  be  made  in  the  direction  of  the  urethra 
with  the  instrument,  while  with  the  fingers  in  the  vagina  the  efforts 
may  be  governed  so  as  to  keep  up  the  right  direction  and  steadiness, 
and  also  to  push  the  stone  into  the  urethra.  Swaying  the  instrument 
in  different  directions,  and  performing  slight  rotation,  the  force  used 
should  be  very  gently  applied  and  slowly  increased,  giving  the  parts 
time  to  stretch,  and  no  more  exerted  than  is  just  sufficient  to  accom- 
plish the  extraction.  We  should  not  be  in  a  hurry,  but  take  plenty 
of  time ;  more  damage  is  done  by  too  great  hurry  than  too  great  dilata- 
tion, I  think.  The  parts  are  torn  instead  of  being  stretched.  If  the 
stone  is  too  large  to  be  removed  in  this  way,  we  may  perform 
lithotomy. 

H.  Marion  Sims  proposed  and  performed  lithotomy  through  the  ves- 
ico-vaginal  septum.  He  exposed  the  parts  as  for  operation  for  vesico- 
vaginal fistula,  introduced  a  curved  director  through  the  urethra,  and 
cut  into  the  bladder  upon  it  until  the  opening  was  large  enough  to 


234  DISEASES    OF    THE   BLADDER. 

permit  the  stone  to  pass.  The  finger  was  then  passed  through  the  arti- 
ficial opening  by  which  the  forceps  was  guided,  the  stone  seized  and 
extracted  through  it.  The  wound  need  not  and  ought  not  to  be  im- 
mediately closed,  nor  until  the  cystitis  is  cured,  then  it  will  generally 
spontaneously  close.     If  not  it  should  be  treated  as  a  fistula. 

Foreign  Bodies. 

Are  sometimes  introduced  into  the  bladder  by  accident  or  design. 
Lead-pencils,  hair-pins,  quills,  etc.,  are  found  in  the  bladders  of  hys- 
terical girls.  They  may  be  generally  easily  extracted  by  dilating  the 
urethra,  seizing  the  substance  with  strong  forceps,  and  withdrawing 
them.  Several  instances  are  recorded  of  the  open-barred  pessaries  of 
Dr.  Hodge  being  removed  from  the  bladder,  where  they  had  been  in- 
troduced by  mistake.  The  practitioner,  starting  one  limb  of  the 
instrument  into  the  urethra  instead  of  the  vagina,  and  afterwards 
manipulating  in  the  ordinary  way,  would  easily  pass  the  whole  into 
the  bladder  without  observing  any  difference  in  the  passage  through 
the  parts.  Dr.  H.  R.  Storer,  of  Boston,  has  now  had  three  cases  of  this 
kind,  and  others  have  also  met  with  them.  I  have  seen  but  one  in- 
stance of  the  accident,  or  rather  mistake.  In  that  case  the  instrument 
was  introduced  by  an  intelligent  physician,  who  was  sick  and  stupefied 
by  opium.  As  he  died  a  few  days  afterward  there  was  no  opportunity 
of  hearing  his  account  of  the  matter.  The  pessary  remained  in  the 
bladder  several  months,  during  which  time  the  patient  was  married 
and  became  pregnant.  Three  months  after  conception  the  instrument 
was  discovered  and  removed  without  interrupting  gestation.  The  re- 
moval was  not  attended  with  much  difficulty.  The  urine  was  all 
drawn,  and  as  the  bladder  emptied  and  contracted  the  pessary,  coming 
down  upon  the  anterior  wall  of  the  vagina,  was  distinctly  felt,  and  its 
shape  and  size  easily  distinguished.  The  little  finger  was  first  pressed 
into  the  urethra  until  it  passed  into  the  bladder,  then  the  index,  by 
which  the  end  of  one  of  the  branches  of  the  instrument  was  drawn  to 
the  vesical  end  of  the  urethra.  The  finger  was  then  withdrawn,  and 
Ricord's  phimosis  forceps  introduced  until  in  contact  with  the  limb  of 
the  pessary.  To  facilitate  the  prehension  of  it  by  the  forceps,  the  in- 
dex finger  of  the  left  hand  in  the  vagina  held  the  pessary  against  the 
pubis.  In  this  way  it  was  not  at  all  difficult  to  fasten  the  forceps  on 
the  end  of  the  limb  lying  in  contact  with  the  neck  of  the  urethra,  and 
extract  the  whole  instrument.  This  was  done  by  first  bringing  the 
point  of  the  branch  seized  upon  out  of  the  meatus,  depressing  it  toward 
the  perineum  until  the  angle  at  the  junction  with  the  cross-bar  ap- 
peared, after  which  the  changes  were  the  same  as  removing  from  the 
vagina.  This  case  was  recorded  by  Dr.  Bulkley,  of  Freeport,  Illinois, 
in  the  Medical  Record.     Essentially  the  same  plan  enabled  Dr.  H.  R. 


INVEESION    OF    THE   BLADDER.  235 

Storer,  of  Boston,  to  relieve  his  patients.  A  foreign  body  that  has  been 
introduced  through  the  urethra  can,  by  this  kind  of  manipulation,  be 
removed  through  it. 

Inversion  of  the  Bladder. 

In  childhood  the  bladder  sometimes  becomes  inverted  and  partially 
expelled  through  the  urethra.  Dr.  John  Croft,  in  "  St.  Bartholomew 
Hospital  Reports,"  American  Practitioner,  gives  the  following  methods 
of  diagnosticating  and  treating  inversion  of  the  bladder : 

"  A  small,  red,  pyriform,  vascular,  elastic  tnmor,  situated  between  the  labia  below  the 
clitoris,  and  in  front  of  the  vaginal  orifice;  the  urethra  not  distinguishable ;  the  ureters 
may  be  exposed,  and  perhaps  distilling  urine;  a  history  of  more  or  less  incontinence 
previous  to  the  appearance  of  the  tumor:  these  symptoms  should  lead  one  to  recog- 
nize an  inversio  vesicce,  and  to  distinguish  such  an  affection  from  a  solid  polypoid 
growth.  Mr.  Holmes  has  described  a  vaginal  hernia  in  his  work  on  Diseases  of  Chil- 
dren. In  that  malady  the  urethra  can  be  found  in  front  of  the  tumor,  which  has  not 
the  red  vascular  appearance  of  an  inverted  vesical  membrane.  The  best  mode  of 
reduction  seems  to  be  by  taxis,  and  the  thumb  and  fingers  the  best  compressors.  They 
should  be  used  gently.  If  the  child  struggle  much,  it  would  be  better  to  employ 
chloroform." 

A  properly  constructed  compress  will  retain  the  parts  in  position 
until  the  urethra  attains  its  normal  tone. 


CHAPTER    IX. 

AFFECTIONS  OF  THE  VAGINA. 

Absence  of  the  Vagina. 

We  observe  absence  of  the  vagina  when  the  tissues  and  organs  in 
near  relations  to  it  are  in  one  of  two  conditions :  First,  when  the 
rectum,  bladder,  and  vagina  are  all  absent  and  replaced  by  one  great 
cavity,  through  which  the  urine  and  feeces  are  passed.  This  cavity 
is  called  by  authors  cloaca,  being  a  common  excretory  canal  for  the 
urinary,  genital,  and  alimentary  organs.  Sometimes  the  vagina  is 
imperfectly  formed,  and  the  rectum  perforates  it  posteriorly,  while 
the  urethra  enters  it  anteriorly.  Secondly,  the  vagina  may  be  absent 
while  the  rectum  and  bladder  are  properly  situated,  perfect  in  their 
formation,  and  the  anus  and  meatus  urinarius  both  also  occupying 
their  normal  places  and  performing  their  functions  properly.  In 
this  last  condition  of  the  parts  the  vulval  organs  are  generally  all 
present;  in  one  case  the  hymen  was  to  be  seen.  In  by  far  the  most 
instances  there  is  an  absence  of  the  uterus  when  the  vagina  is  not 
found,  but  this  is  not  always  the  case. 

Causes. 
Absence  of  the  vagina  is,  of  course,  always  a  congenital  condition. 

Diagnosis. 

In  cases  in  which  there  is  a  common  cavity  for  the  rectum  and  blad- 
der, we  shall  have  no  difficulty  in  ascertaining  it  by  inspecting  the  parts 
with  the  eye  and  passing  the  probe  into  the  rectum  and  bladder  if 
necessary.  The  discharges,  however,  will  generally  enable  us  to  decide 
without  this  last  measure.  When  all  the  adjacent  organs  are  normal, 
we  are  to  distinguish  between  occlusion  by  an  abnormal  hymen, 
rudimentary  vagina,  and  this  condition. 

Physical  examination  alone  will  enable  us  to  do  this.  We  shall 
not  often  be  called  upon  to  determine  the  question  of  diagnosis  until 
there  is  a  collection  of  menstrual  fluid  in  the  cavity  of  the  uterus,  or 
the  patient  is  married. 

When  there  is  occlusion  by  the  hymen,  with  a  collection  of  fluid  in 
the  vagina,  the  vulva  will  be  occupied  by  a  tumor  formed  of  the 
pouting  membrane,  generally  of  a  dark-purple  color  and  hemispherical 
in  shape,  giving  the  sense  of  fluctuation  when  pressed  upon  at  the 


ATRESIA  VAGINA.  237 

time  the  hypogastric  region  is  j)ercussecl.  "When  the  vagina  is  absent, 
there  will  be  a  tumor  perceptible  between  the  bladder  and  rectum, 
but  no  protrusion  between  the  labia.  The  ordinary  sign  so  often 
mentioned  of  a  cord-like  hardness  extending  from  the  vulva  upward 
is  of  no  use,  as  this  is  obscured  by  the  globular  mass  between  the 
rectum  and  bladder. 

The  treatment  of  absence  of  the  vagina  will  be  given  in  the  treat- . 
ment  of  atresia. 

Atresia  Vagin%. 

This  condition  arises  very  much  more  frequently  from  puerperal 
inflammation  of  the  vaginal  parietes  than  any  other  cause.  But  any- 
thing that  j)roduces  inflainmation  enough  to  destroy  the  epithelium 
of  the  mucous  membrane  may  cause  atresia,  as  mechanical  or  chemical 
agencies,  scarlatina,  measles,  syphilis,  etc. 

After  extensive  ulceration  from  these  or  other  cases,  if  the  denuded 
surfaces  are  allowed  to  remain  in  contact  and  at  rest  for  a  time,  the}'' 
contract  adhesions,  thus  narrowing,  or  even  at  times  completely  closing, 
the  cavity.  In  atresia  occurring  as  the  effect  of  inflammation  every 
variety  may  be  observed.  The  vagina  may  be  closed  at  the  vulva 
and  not  above,  the  centre  may  be  contracted  and  the  upjDcr  and  lower 
ends  be  of  normal  dimensions,  or  the  adhesion  may  take  place  at  the 
upper  part,  including  or  not  the  os  uteri.  In  all  these  varieties,  how- 
ever, the  parts  not  involved  in  the  ulceration  are  but  little  affected. 
Atresia  may  also  be  a  congenital  defect  in  the  organization.  Con- 
genital atresia  is  more  frequently  caused  by  the  formation  of  a  mem- 
brane across  the  cavity,  closing  it  in  some  part,  as  the  hymen  occa- 
sionally closes  the  vulva,  and  which  is  often  so  low  down  as  to  be 
confounded  with  that  membrane.  Such  a  closure,  however,  is  usually 
farther  up  the  cavity,  sometimes  near  the  os  uteri.  Partial  congenital 
atresia  is  sometimes  represented  by  a  very  narrow  canal,  only  large 
enough  to  admit  a  probe,  and  which  seems  a  very  imperfect  outlet  for 
the  menstrual  discharge,  and  is  so  small  as  to  prevent  sexual  inter- 
course. This  form  of  atresia  may  be  complete  and  "  the  organ  changed 
into  a  solid  cord,"  extending  in  part  or  the  whole  of  its  length. 

Diagnosis. 

Judging  from  my  own  observation  we  are  more  frequently  called 
ui^on  for  a  diagnosis  in  atresia  after  jDuberty  than  before.  Previous 
to  puberty  the  closure  of  the  external  ojjening  to  the  vagina  would 
be  the  only  condition  likely  to  lead  to  its  discovery.  The  diagnosis 
in  such  cases  is  of  little  importance  comijared  to  what  it  becomes  after 
adult  age,  as  the  defect  does  not  interfere  with  the  function  of  the 
organ.  The  failure  in  the  appearance  of  the  menses  at  the  proper 
time  in  life,  pain  in  the  pelvic  region,  and  enlargement  of  the  abdo- 


238  AFFECTIONS    OF    THE   VAGINA. 

men  generally  call  for  physical  investigation.  If  it  has  originated  in 
ulcerative  inflammation,  the  retention  of  menstrual  fluid,  pain  and 
enlargement  would  soon  excite  suspicion ;  or,  if  the  patient  is  married, 
the  husband  would  be  likely  to  discover  the  unusual  state  of  things. 
Practically  a  very  large  majority  of  the  cases  we  meet  with  will  be 
attended  with  an  accumulation  of  fluid.  The  history  of  the  case,  the 
fluctuating  tumor  between  the  bladder  and  rectum,  felt  by  the  finger 
in  this  last  cavity  and  the  catheter  in  the  first  viscus,  and  the  presence 
of  some  part  of  the  vagina  in  a  distinguishable  condition  will  enable 
us  to  decide  as  to  the  nature  of  the  difficulty. 

Prognosis. 

There  are  very  few  cases  of  acquired  atresia  which  do  not  admit 
of  more  or  less  complete  relief.  Congenital  atresia  with  membranous 
formation  across  the  cavity  is  generally  curable,  and  when  the  vaginal 
cavity  is  so  contracted  as  to  be  nearly  but  not  entirely  obliterated, 
we  may  hope  for  a  cure,  but  when  it  is  attended  with  defective  de- 
velopment of  the  other  genital  organs  we  may  expect  much  difficulty, 
even  if  a  cure  be  practicable. 

Treatment  of  Atresia  and  Absence  of  the  Vagina. 

The  object  of  treatment  is  to  overcome  by  surgical  means  the  ob- 
struction to  the  discharges  from  the  uterus.  The  vagina  is  a  viaduct 
for  the  uterine  discharges.  This,  to  be  sure,  does  not  express  all  the 
uses  of  that  organ,  but  to  make  it  an  efficient  channel  for  the  menses 
is  really  almost  the  only  reason  for  operation  in  the  graver  varieties 
of  vaginal  atresia.  We  are  not,  therefore,  justified  in  submitting  our 
patient  to  the  dangerous  operation  of  opening  up  the  vaginal  canal 
for  any  other  purpose.  In  cases,  therefore,  in  which  the  uterus  is 
absent  we  are  not  justified  in  attempting  to  form  an  artificial  vagina, 
or  in  any  way  endeavoring  to  perfect  the  organs  for  conjugal  purposes 
merely.  I  have  known  but  one  attempt  of  this  kind,  and  in  that  case 
no  success  attended  the  persevering  and  ingenious  eff'orts  of  Dr. 
Brainard.  The  patient  was  a  married  woman,  who  said  she  assumed 
matrimonial  relations  without  knowing  that  she  was  not  like  other 
women.  The  vagina  terminated  in  a  cul-de-sac  about  an  inch  in 
depth.  Her  husband  complained  of  her  incapacity  to  fulfil  the  duties 
of  a  wife.  They  visited  Dr.  Brainard  for  surgical  aid,  and  he  had  the 
kindness  to  allow  me  to  witness  his  operations.  Although  the  artifi- 
cial canal  that  resulted  from  his  efforts  was  two  inches  in  depth,  it 
had  a  constant  tendency  to  contract,  and  required  the  steady  employ- 
ment of  a  glass  plug  to  keep  it  open.  The  husband  was  not  satisfied, 
and  the  law  allowed  him  to  separate  from  her. 

The  occlusion  should  not  be  operated  upon  until  the  menstrual 


TEEATMENT   OF   ATEESIA   AND   ABSENCE   OF   THE   VAGINA.      239 

fluid  fills  up  the  uterus  and  distends  the  parts  between  its  cavity  and 
the  vulva.  Ordinarih^,  when  the  vagina  is  absent,  the  uterus  is  bound 
by  areolar  and  fibrous  tissues  to  its  usual  situation  in  the  pelvis,  and 
as  distension  occurs  the  lower  portion  of  the  organ  approaches  very 
near  the  vulva, — in  two  instances  of  absence  of  the  vagina  it  was  not 
more  than  an  inch  and  a  half  from  the  vulva.  In  thus  approaching 
the  external  organs  it  widely  separates  the  bladder  and  rectum ;  press- 
ing the  former  up  behind  the  pubis,  and  the  latter  strongly  into  the 
hollow  of  the  sacrum. 

This  condition  of  things  makes  an  operation  for  the  opening  of  the 
vagina,  or  making  an  artificial  canal,  comparatively  easy  and  safe. 
To  attempt  to  reach  the  uterus  of  a  girl  before  puberty  has  estab- 
lished the  menses,  by  cutting  up  toward  that  organ  from  the  vulva, 
is  to  undertake  a  task  of  very  great  difficulty  and  hazard,  which, 
after  the  distension  has  brought  about  the  changes  above  described, 
may  be  accomplished  with  great  certainty  and  facility  and  much  less 
risk.  Much  delay,  permitting  of  great  distension,  should  also  be 
avoided,  for  Puesch  tells  us  that  in  258  cases  of  atresia  18  died  of 
rupture  of  the  Fallopian  tube. 

The  right  time,  then,  to  operate  for  complete  atresia  is  as  soon  as 
the  uterine  tumor  fairly  fills  the  pelvis,  and  when  by  touch  through 
the  rectum  with  the  finger,  with  a  catheter  in  the  urethra,  we  can 
assure  ourselves  that  the  uterus  can  be  easily  reached  without  endan- 
gering any  important  organ. 

Scanzoni  was  so  impressed  with  the  danger  of  wounding  the  bladder 
and  rectum  that  he  advised  evacuating  the  imprisoned  menstrual  fluid 
by  introducing  a  curved  trocar,  of  large  calibre,  into  the  rectum,  and 
plunging  it  into  the  most  dependent  part  of  the  tumor.  After  the 
flow  of  blood  has  ceased,  the  canula  should  be  left  in  the  place  for 
some  time  in  order  to  establish  a  permanent  opening.  I  think  the 
danger  of  this  operation  was  overestimated  by  Scanzoni,  and  cannot 
recommend  the  student  to  follow  his  teaching.  With  the  precautions 
as  to  time  and  circumstances,  and  the  proper  care,  the  hazard  is  much 
less  than  he  has  estimated  it.  The  patient  may  be  placed  in  the  lith- 
otomy position,  a  catheter  introduced  into  the  bladder  and  a  finger 
into  the  rectum.  The  catheter  will  be  directed  strongly  up  behind 
the  symphysis  pubis,  and  the  finger  pressed  firmly  back  against  the 
sacrum.  These  preliminary  measures  being  instituted,  an  exploring 
trocar  may  be  passed  into  the  central  line  of  the  vulva  about  half  an 
inch  below  the  urethral  orifice,  and  pushed  backward  into  the  tumor. 
If  the  trocar  has  entered  the  cavity  containing  the  menstrual  fluid, 
this  will  begin  to  pass  the  canula  upon  the  withdrawal  of  the  stilet. 
When  thus  assured  of  the  right  direction,  we  may  be  guided  by  the 
trocar  in  making  an  incision  that  should  be  run  along  the  lower  side 
of  it,  until  the  opening  is  large  enough  to  press  the  forefinger  through 


240  AFFECTIONS   OF   THE   VAGINA. 

it.  With  this  member  we  may  tear  the  opening  large  enough  to  admit 
the  middle  finger  with  it.  Through  this  opening  the  blood  will  soon 
be  evacuated.  As  soon  as  this  is  the  case,  the  cavity  of  the  uterus  and 
vagina  ought  to  be  thoroughly  cleansed  by  tepid  water  thrown  plen- 
tifully through  a  tube  long  enough  to  reach  to  the  fundus.  The  arti- 
ficial opening  thus  made  must  be  kept  open  by  confining  a  glass  plug 
large  enough  to  keep  it  patulous.  This  plug  should  be  worn  for  sev- 
eral weeks,  and  recourse  be  had  to  it  when  retraction  threatens  to 
obliterate  the  canal. 

Hewett  recommends  tearing  through  the  obstructing  tissue  instead 
of  puncturing  or  cutting.  Others  dissect  through  with  the  knife.  Dr. 
T.  A.  Emmet  advises  us  to  use  the  scissors  for  incision  into  the  tumor. 
And,  again,  a  large  trocar  sometimes  is  used  to  penetrate  the  cavity 
at  the  point  I  have  directed,  and  the  finger  used  to  enlarge  the  open- 
ing made  by  it.  It  happens  in  some  cases  that  severe  symptoms  fol- 
low this  operation  for  the  sudden  evacuation,  such  as  peritonitis, 
metritis,  etc.  Dr.  J.  Marion  Sims,  to  avoid  this,  evacuated  the  fluid 
very  slowly,  allowing  the  uterus  to  contract  on  the  receding  fluid  as 
fast  as  evacuated. 

In  cases  where  the  hymen  or  other  membrane  closes  the  vaginal 
canal,  the  considerations  above  stated  should  induce  us  to  wait  until 
there  is  a  moderate  accumulation  of  menstrual  fluid  in  the  vagina. 
The  division  may  then  be  made  with  scissors  carried  up  to  the  mem- 
brane. The  opening  should  be  free.  Not  much  danger  of  cicatrical 
contraction  closing  up  the  divided  part  will  exist,  yet  for  several  days 
the  finger  should  be  passed  above  the  obstruction  daily  to  prevent  any 
tendency  of  that  kind.  When  the  vaginal  canal  is  contracted  to  very 
small  dimensions,  amounting  to  almost  complete  atresia,  we  may 
dilate  this  small  opening  by  introducing  rubber  or  metallic  bougies 
graduated  in  size,  the  smaller  first  and  larger  afterwards.  Sponge  tents 
may  be  used  after  the  dilatation  has  been  fairly  begun.  Perseverance 
in  the  use  of  tents  will  enable  us  to  succeed  without  cutting,  and  I 
would  very  much  prefer  it  to  any  other  method  of  procedure.  The 
vagina  may  be  kept  open  by  the  prolonged  use  of  a  glass  plug. 

Tumors  in  the  Vagina. 

Fibrous  tumors  in  the  vagina  are  occasionally  met  with.  They  are 
generally  less  firm,  although  resembling  in  most  other  respects  the 
fibrous  growths  of  the  uterus.  They  grow  in  the  anterior  wall  of  the 
vagina  so  as  to  project  into  the  bladder  and  vagina  to  about  the  same 
extent,  or  more  or  less  in  either  of  these  cavities,  according  as  they 
are  developed  nearest  the  membrane  of  the  one  or  the  other.  Some- 
times they  are  pendulous  or  polypoid,  hanging  into  the  vaginal  cavity 
by  a  neck  of  greater  or  less  size.     All  I  have  seen  of  the  intramural 


VAGINISMUS.  241 

form  of  these  tumors  were  encysted,  and  were  removed  by  excision. 
The  cyst  was  ojiened  and  the  tumor  turned  out  and  the  wound  allowed 
to  close  by  contraction  and  granulation.  The  polypoid  form  may  be 
removed  by  the  ecraseur  or  ligature.  The  6craseur  is  very  much  to 
be  preferred.  Fatty  encysted  tumors  of  the  vagina  are  more  rarely 
met  with,  and  may  be  dissected  out,  in  the  same  manner  as  if  situated 
elsewhere. 

Cysts  of  various  sizes  containing  fluid  are  also  not  infrequent.  These 
may  be  cured  by  cutting  out  a  portion  of  the  cyst  wall  large  enough 
to  keep  the  incision  from  closing  until  the  lining  membranes 
granulate. 

Vaginismus. 

J.  Marion  Sims  described  this  affection  first  to  the  Obstetrical  So- 
ciety of  London,  December,  1861,  and  afterwards  gave  it  to  us  in  his 
Clinical  Notes  on  Uterine  Surgery.  It  is  an  "  hypersesthesia  of  the  vulva 
and  hymen,  attended  with  involuntary  contraction  of  the  sphincter 
vaginse."  The  parts  are  so  very  sensitive  that  the  slightest  touch  with 
the  finger  causes  great  pain,  and  in  some  instances,  coition  is  entirely 
impracticable.  In  all  the  cases  I  have  ever  examined,  there  was  very 
decided -redness  and  increase  of  the  secretion  of  the  parts  exposed  by 
separating  the  labia.  Dr.  Sims  thought  the  sensitiveness  confined  to 
the  vulva  and  hymen,  but  I  apprehend  that  more  extended  observa- 
tion will  establish  the  fact  that  the  whole  vagina  is  often  involved. 
In  one  of  my  cases,  now  under  treatment,  the  sensitiveness  of  the 
vulva  has  almost  entirely  disappeared ;  the  finger  may  be  introduced 
into  the  vagina,  but  the  upper  part  of  this  cavity  is  so  exquisitely 
tender  that  the  patient  screams  with  pain  as  the  finger  approaches  the 
cervix  uteri. 

The  general  symptoms  of  this  affection  are  grave  according  to  the 
chronicity  of  the  case.  It  generally  shatters  the  constitutional  energies 
of  the  patient,  rendering  her,  according  to  the  expression  of  Dr.  Sims, 
a  wreck.  He  considered  it  independent  of  inflammation.  Mr.  I.  B. 
Brown  agreed  with  him.  It  is,  according  to  them,  mere  hypersesthesia. 
In  my  cases  the  parts  were  always  in  a  state  of  inflammation ;  but  I 
cannot  think  the  hypersesthesia  was  wholly  of  inflammatory  origin. 
Of  course  I  am  not  prepared  to  say  that  inflammation  is  even  a  general 
attendant.  The  observation  of  the  profession  will  soon  determine  that 
point,  as  the  disease  is  now  fairly  set  before  it,  and,  from  the  distress- 
ing symptoms,  will  attract  much  attention.  My  patients  have  appa- 
rently not  been  aware  of  their  condition  until  married.  The  intensity 
of  the  suffering  is  not  always  sufficient  to  prevent  coition,  and  some- 
times is  much  greater  than  others.  The  sensitiveness  is  greater  near 
the  menstrual  epoch,  occasionally  in  a  very  marked  degree.  My  pa- 
tients have  all  been  barren. 

16 


242  AFFECTIONS   OF    THE    VAGINA. 

Diagnosis. 

The  sensitiveness  and  contraction  are  characteristic,  and  hence 
there  is  no  need  of  much  labor  in  forming  a  diagnosis.  The  least 
touch  of  the  mucous  membrane  of  the  vulva,  with  a  feather,  soft 
brush,  or  fingers,  gives  the  patient  great  suffering,  and  sometimes 
agony  unlike  anything  else. 

P7'ognosis. 

Judging  from  all  I  have  seen  and  read  upon  the  subject,  there  is 
very  little,  if  any,  tendency  to  spontaneous  subsidence.  Its  duration, 
therefore,  is  perplexingly  long.     But  all  agree  as  to  its  curability. 

Treatment. 

The  late  Dr.  Sims  succeeded  in  curing  all  his  cases  by  dividing  the 
sphincter  vaginse  deeply  on  either  side  of  the  vaginal  orifice  near  the 
fourchette.  He  made  the  division  sufficiently  deep  to  permit  of  free 
dilatation,  and  then  kept  the  vagina  open  with  large  bougies  until 
the  wound  cicatrized.  The  results  of  this  operation  are  all  that  might 
be  expected  from  it.  The  hypersesthesia  disappears,  and  the  obstacles 
to  coition  are  removed,  but  there  is  necessarily  great  mutilation.  A 
long  time  before  Dr.  Sims  wrote  on  the  subject,  forcible  dilatation  was 
recommended  to  overcome  the  spasmodic  contraction  of  the  sphincter 
vaginse.  Perhaps  the  best  and  most  convenient  way  to  dilate  the 
vagina  is  to  introduce  the  thumb  of  each  hand  into  the  vagina,  with 
the  palmar  surface  turned  outward,  and  then  forcibly  separate  them 
as  far  as  possible.  This  will  stretch  the  vulva,  but  not  often  rupture 
the  muscular  fibres  to  any  great  extent.  After  thus  forcibly  dilating, 
we  should  introduce  the  glass  plug,  recommended  by  Dr.  Sims,  twice 
a  day,  morning  and  evening,  and  allow  it  to  remain  each  time  from 
one  to  two  hours.  The  plug  ought  to  be  from  one  to  two  inches  in  diam- 
eter. The  introduction  and  presence  of  this  hard  substance  at  first 
gives  great  pain,  and  we  may  be  under  the  necessity  of  using  aneesthetics 
or  anodynes,  to  enable  our  patient  to  bear  it ;  but  after  having  been 
several  times  introduced,  the  parts  tolerate  it  better,  and  finally  we  can 
use  it  without  giving  the  patient  any  great  inconvenience.  The  de- 
creasing sensitiveness  thus  manifested  will  be  a  guide  to  us  in  deciding 
when  to  discontinue  it.  Mr.  I.  Baker  Brown,  in  his  Surgical  Diseases 
of  Females,  condemns  Dr.  Sims's  operation  as  severe  and  needless,  and 
gives  two  cases  where  the  sensitiveness  was  cured  by  the  relief  of 
fissure  of  the  rectum.  He  thinks  the  hypertesthesia  is  a  symptom  of 
some  disease  of  the  rectum,  generally  fissure ;  and  that  by  incision  of 
the  fissures  it  will  disappear.  Dr.  Braun,  of  Vienna,  according  to  Mr. 
Brown,  has  cured  one  case  by  removing  the  clitoris.  A  case  of  some 
severity  is  reported  in  the  London  Lancet,  American  reprint  for  March, 


ACUTE   VAGINITIS.  243 

1867,  in  the  care  of  Dr.  G.  C.  P.  Murray,  in  which  the  hypergesthesia 
appeared  to  depend  upon  inflammation  of  the  cervix  uteri  and  vagina. 
It  was  cured  by  making  a  free  application  of  the  solid  nitrate  of  silver 
over  the  inflamed  cervix,  and  a  solution  to  the  vaginal  surface.  These 
applications  were  repeated  in  a  fortnight,  and  were  succeeded  by  the 
tincture  of  iodine.  While  there  can  be  no  doubt  that  Dr.  Sims's  plan 
is  efficacious,  I  cannot  think  it  necessary,  and  the  success  of  other 
means  by  different  practitioners  bears  me  out  in  this  opinion.  We 
almost  always  find  the  patients  in  a  state  of  unsatisfactory  health,  and, 
according  to  my  observation,  evident  local  disease  besides  that  of  sen- 
sitiveness ;  and,  from  what  we  have  learned  from  Mr.  Brown  and  Dr. 
Murray,  more  than  one  kind  of  local  disease.  As  in  the  treatment  of 
all  other  diseases,  therefore,  we  should  carefully  and  diligently  search 
for  and  cure  the  cause  of  the  hypersesthesia.  If  it  is  fissure  of  the  rec- 
tum, this  should  receive  our  first  attention  ;  if  inflammation  of  the 
vagina,  uterus,  or  vulva,  we  ought  to  cure  this. 

In  all  the  cases  I  have  seen,  and  I  now  have  three  under  treatment, 
nothing  I  have  tried  has  been  of  so  much  advantage  as  remedies 
directed  against  inflammation  of  the  vagina  and  vulva.  The  course  I 
usually  pursue  is  to  apply  the  solid  nitrate  of  silver  to  the  vulva 
every  ten  or  fourteen  days,  and  in  the  interval  use  glycerin  and  tannin. 
The  first  application  reduces  the  sensitiveness  very  decidedly,  and  it 
becomes  less  after  each  successive  touch,  until  finally  cured.  We 
should  bear  in  mind  that  the  hypera3sthesia  does  extend  into  the 
vagina  and  to  the  uterus,  and  that  it  is  as  necessary  to  treat  the  vaginal 
cavity  as  the  vulva.  I  have  been  in  the  habit,  at  first,  of  managing 
it  as  I  would  vaginitis.  The  strong  astringents,  glycerin  and  narcotics, 
applied  by  means  of  medicated  pessaries  and  injections,  are  valuable 
adjuncts.  With  the  local  treatment,  rational  general  treatment  is 
very  beneficial.  Attention  to  the  bowels,  the  condition  of  the  stomach,, 
and  the  secretions  generally ;  tonics,  exercise,  change  of  air,  bathing, 
attention  to  clothing,  and  all  the  regiminal  circumstances  calculated 
to  benefit  the  general  condition  of  the  patient. 

Acute  Vaginitis. 

Begins  generally  in  the  lower  part  of  the  vagina,  with  swelling,  in- 
tense redness,  and  dryness  of  the  mucous  surfaces  of  the  labia,  vulva 
and  vagina.  There  is  great  heat  in  the  parts,  and  the  patient  com- 
plains of  burning  pain  in  them.  Difficult,  painful  micturition,  pain 
in  passing  the  faeces,  sense  of  weight  in  the  pelvis,  and  tenesmus  are 
generally  present  also.  Not  unfrequently  there  is  backache  and  pain, 
radiating  down  the  thighs,  into  the  hips,  up  the  spine,  and  into  the 
head.  Sometimes  the  symptoms  are  so  acute  as  to  jDroduce  general 
febrile  disturbance.     When  this  is  the  case,  there  is  chilliness  alternat- 


244  AFFECTIONS    OF   THE   VAGINA. 

ing  with  heat,  an  increased  frequency  of  the  pulse,  furred  tongue, 
pain  in  the  limbs,  etc.  In  the  course  of  thirty-six  hours  the  pain, 
redness,  and  swelling  spread  to  the  whole  of  the  vaginal  cavity,  and 
soon  there  is  a  profuse  secretion  of  mucus,  which,  after  two  or  three 
days,  or  even  sooner,  is  mixed  with  pus-globules  in  some  abundance. 
When  this  last  is  the  case,  the  discharge  is  either  green  or  yellowish  in 
color,  and  less  tenacious.  This  state  of  things  lasts  for  from  ten  to 
twenty  days,  when  the  inflammation  gradually  subsides,  becomes  less 
in  quantity  and  lighter  in  color,  until  in  four  or  five  weeks  the  disease 
is  entirely  gone,  or  it  merges  into  the  chronic  form.  The  inflamma- 
tion usually  involves  the  urethra,  and  sometimes  the  bladder,  and  its 
greatest  intensity  is  almost  always  in  the  lower  third  of  the  vaginal 
canal.  The  inflammation  sometimes  spreads  to  the  rectum.  Some- 
times it  attacks  the  mucous  membrane  of  the  cervix  uteri,  and  even 
invades  the  cavities  of  the  corpus  uteri  and  Fallopian  tubes,  remain- 
ing longer  in  these  localities  than  in  the  vaginal  cavity. 

Diagnosis. 

The  diagnosis  of  acute  vaginitis  is  not  difficult,  as  the  parts  may  be 
easily  seen  and  touched. 

Prognosis. 

As  has  been  heretofore  intimated,  it  subsides  spontaneously,  and 
leaves  the  parts  free  from  disease,  or  in  a  state  of  chronic  inflamma- 
tion.    The  prognosis,  therefore,  is  favorable. 

Cause. 

It  is  caused  by  contagion  more  frequently,  perhaps,  than  anything 
else,  but  does  doubtless  arise  from  abuses,  injuries,  and  want  of  clean- 
liness, and  probably  other  causes.  I  have  seen  the  non-contagious 
form  in  children  very  much  more  frequently  than  in  adults,  spread- 
ing usually  from  the  vulva  upwards.  Non-contagious  acute  vaginitis 
is  not  a  very  common  affection.  At  first  it  involves  the  mucous  mem- 
brane and  submucous  tissue,  but  before  many  days  it  is  confined  to 
the  membrane  alone. 

Treatment. 

This  at  first  should  be  slightly  antiphlogistic.  A  few  grains  of  calo- 
mel, followed  in  ten  or  twelve  hours  with  a  saline  cathartic,  should  be 
the  first  step.  This  may  be  succeeded  by  nauseating  doses  of  tartar 
emetic,  until  the  dryness  and  swelling  have  subsided.  In  the  mean- 
time, perfect  quiet  in  the  recumbent  position  should  be  enjoined, 
the  parts  bathed  every  hour  or  two  thoroughly  with  tepid  water,  and 
the  patient  should  abstain  from  stimulating  or  nutritious  ingesta.  As 
soon  as  the  discharge  has  become  copious,  and  yellowish  or  green,  and 


CHEOXIC    VAGINITIS.  245 

the  swelling  of  the  parts  has  entirely  subsided,  the  treatment  should 
be  changed  for  astringents,  specifics,  laxatives,  and  baths.  We  may 
give  half  a  drachm  of  balsam  copaiba  in  emulsion  or  capsules  every 
six  or  eight  hours,  and  have  the  vagina  syringed  copiously  with  a 
saturated  solution  of  alum,  or  acetate  of  lead,  two  or  three  times  in 
twenty -four  hours.  Every  third  day  a  few  ounces  of  a  solution  of  ni- 
trate of  silver,  the  strength  of  ten  grains  to  the  ounce,  may  be  advan- 
tageously used.  The  bowels  should  be  kept  open,  and  the  patient 
should  abstain  from  stimulants  at  all  times  during  the  treatment.  The 
astringent  injection  ought  to  be  changed  every  five  or  six  days,  using 
alum,  sugar  of  lead,  and  sulphate  of  zinc  alternately.  Perseverance 
in  this  treatment  will  very  materially  shorten  the  course  of  the  disease. 

Chronic  Vaginitis. 

This  is  a  more  frequent  form  of  disease  than  the  acute,  and  its  im- 
portance will  be  understood  from  this  consideration.  It  is  in  many 
instances  a  ver}^  distressing  affection,  and  often  mistaken  for  diseases 
of  the  uterus,  bladder,  or  rectum. 

Symptoms. 

There  is  generally  jiain  in  the  back,  more  frequently  in  the  sacrum, 
and  coccyx,  but  not  seldom  higher  up  ;  pain  in  the  groin,  weight  and 
sense  of  bearing  down  in  the  perineum,  dragging  in  the  hips  and 
pelvis.  A  burning  sensation  in  the  vagina,  extending  all  over  the 
lower  part  of  the  person,  very  distressing  and  depressing,  is  sometimes 
the  chief  symptom  complained  of  b}^  the  patient.  In  married  patients 
it  is  the  cause  of  distress  during  the  act  of  coition,  to  such  a  degree 
sometimes  as  to  entirely  preclude  such  indulgence.  I  am  now  treat- 
ing a  patient  who  assures  me  that  although  she  has  been  married  fifteen 
years,  she  does  not  remember  a  single  instance  of  sexual  intercourse 
that  did  not  give  her  discomfort ;  generally  it  was  the  cause  of  decided 
pain,  and  sometimes  was  entirely  intolerable  to  her.  Leucorrhoea  is  a 
common,  but  not  invariable  symptom  ;  it  may  be  yellow  or  white  in 
color,  but  when  the  case  is  not  complicated  with  cervical  inflammation 
it  is  always  thin.  In  chronic  vaginitis  there  is  generally  a  long  train 
of  sjmipathetic  symptoms  not  unlike  those  observed  in  diseases  of  the 
uterus.  The  nervous  centres  are  disordered  in  their  functions,  pro- 
ducing nervous  symptoms  of  almost  every  description.  The  mind  is 
sometimes  affected  by  it  to  irascibility,  despondency,  suspiciousness, 
jDeevishness,  and  purposeless  instability.  In  other,  or  perhaps,  the 
same  cases  there  is  palpitation  of  the  heart  and  large  vessels  to  such  a 
degree  as  to  cause  alarm  for  the  life  of  the  patient.  Headache  should 
be  mentioned  as  quite  common  ;  it  is  more  commonly  located  in  the 
occipital  region,  but  may  be  in  the  top,  forehead,  temples,  or  all  over 


246  AFFECTIOXS    OF   THE   VAGIXA. 

the  head.  The  eyes  are  generally  weak.  The  stomach  is  frequently 
deranged  to  a  considerable  extent,  and  in  various  ways  ;  and  there  is 
generally  a  constipated  state  of  the  bowels,  though  diarrhoea  is  an 
occasional  symptom.  There  often  is  pain,  too,  in  urinating,  and  in 
passing  the  fgeces  through  the  rectum.  The  uterus  is  almost  always 
affected  also,  and  through  it  the  symptoms  may  become  greatly  diver- 
sified and  increased.     We  should  expect  this  complication. 

Diagnosis. 

Upon  examining  the  vagina,  the  introduction  of  the  finger  will  give 
some  pain,  sometimes  a  good  deal,  and  the  speculum  causes  a  great 
amount  of  suffering.  There  is  general  redness  of  the  mucous  mem- 
brane; sometimes  it  is  smooth  and  moist  merely,  or  covered  with  a 
copious  secretion  of  mucus  ;  in  some  instances  numerous  granulations 
may  be  seen.  The  granulations  may  be  situated  at  the  uj)per  end  of 
the  vaginal  cavity  entirely,- as  I  have  often  seen,  or  in  the  lower  por- 
tion ;  rarely  they  extend  from  one  end  of  the  vagina  to  the  other.  And 
again  the  membrane  may  be  so  raw  as  to  bleed  upon  the  use  of  instru- 
ments in  making  the  examination.  The  sensitiveness,  redness,  and 
exaggerated  secretion  are  conclusive  and  diagnostic  symptoms  when 
they  are  permanent. 

Causes. 

Chronic  vaginitis  is  often  the  result  of  an  acute  attack.  The  inflam- 
mation only  partially  subsides  at  the  time,  and  is  continued  indefinitely. 
Some  of  the  most  obstinate  cases  I  have  met  with  have  thus  resulted 
from  gonorrhoea.  Another  set  of  cases  are  seen  in  i^atients  whose  hus- 
bands were  the  subjects  of  syphilis  or  gonorrhoea  in  early  life,  but 
who  have  been  to  all  appearances  cured.  I  am  inclined  to  the  ojoinion 
that  chronic  vaginitis  is  not  an  uncommon  occurrence  in  women  thus 
situated.  It  is  more  likely  to  follow  recent  cases  of  syphilis,  and  is  some- 
times subacute  in  grade.  Another  form  is  apparently  produced  by 
abortions,  colds,  and  other  causes,  with,  at  the  same  time,  inflammation 
of  the  cervix  uteri.  Constipation  causing  sluggishness  of  the  vaginal 
circulation,  or  other  causes  producing  this  vascular  condition,  as  the 
pressure  from  pelvic  tumors,  phlegmonous  effusion,  etc.,  contribute  to 
the  production  of  chronic  vaginitis.  There  is  no  doubt  but  that  certain 
constitutional  taints,  as  scrofula,  rheumatism,  and,  as  before  intimated 
syphilis,  are  efficient  co-operating  causes. 

Prognosis. 

Chronic  vaginitis,  in  its  simpler  forms,  is  apt  to  be  obstinate  and  resist 
judicious  treatment  for  years.  It  is  more  particularly  so  when  origi- 
nating in  constitutional  diseases.  When  connected  with  incurable 
l;Uin.orj5  it  will,  of  course,  resist  all  treatment. 


CHRONIC   VAGINITIS.  247 


Treatment. 


The  constitutional  treatment  of  chronic  vaginitis  is  sometimes  of  the 
first  importance,  while  at  other  times  it  is  unnecessary,  or  nearly  so. 
The  variety  which  seems  to  be  connected  with  the  syphilitic  condition 
requires  the  alterative  remedies  which  are  found  beneficial  in  this  af- 
fection under  other  circumstances,  the  preparations  of  mercurj^,  iodine. 
and  the  vegetable  alteratives,  for  instance.  When  associated  with 
scrofula  the  vegetable  tonics,  with  alterative  treatment,  cod-liver  oil, 
plenty  of  outdoor  exercise,  cold  bathing,  seabathing,  etc.,  will  be  appro- 
priate measures  to  be  employed.  As  it  is  not  unfrequently  complicated 
with  rheumatism,  or  this  diathesis,  it  may  be  necessary  to  prescribe  for 
it  with  such  a  consideration  in  mind. 

But  in  more  simple  cases,  where  there  are  no  such  taints  or  compli- 
cations, conditions  exist  that  require  a  judicious  course  of  general  treat- 
ment for  their  removal  before  we  can  be  successful  in  our  main  object. 
Such  is  a  torpid  state  of  the  bowels  and  portal  circle,  with  scanty 
secretions.  Mercurial  and  saline  laxatives,  vegetable  tonics,  as  the  bit- 
ters, also  alkalies,  will,  when  judiciously  used,  assist  us  very  much. 
We  should  be  particularly  careful  to  avoid  a  loaded  or  impacted  state 
of  the  rectum,  as  this  is  the  cause  of  much  vaginal  congestion.  An  in- 
jection once  or  twice  a  day,  when  necessary,  will  suffice  for  this. 

In  all  forms,  in  addition  to  the  general  treatment,  when  that  is 
necessary,  we  shall  be  under  the  necessity  of  resorting  to  local  meas- 
ures. Much  benefit  will  be  derived  from  a  sitz-bath  twice  a  day.  The 
bath  should  be  tepid,  as  a  general  thing,  as  being  more  likely  to  agree 
with  the- largest  number  of  patients.  When  it  is  more  agreeable,  the 
bath  may  be  cooler.  It  should  be  large  enough  to  cover  the  hips,  and 
the  patient  should  remain  in  it  for  an  hour  at  least,  and  often  it  is  better 
to  use  it  for  a  greater  length  of  time.  Of  more  importance  are  injec- 
tions. Simple  water  in  large  quantities  is  sometimes  sufficient,  but 
more  frequently  astringent  substances  will  be  found  essential.  The 
injections  should  be  administered  through  a  perpetual  syringe,  and 
the  quantity  should  be  large,  say  from  one  quart  to  a  gallon  of 
water  at  each  time.  The  common  astringents,  as  alum,  sulphate  of 
zinc,  acetate  of  lead,  of  the  strength  of  one  drachm  to  the  quart  of 
water,  will  generally  suffice.  We  find  cases,  however,  in  which  none 
of  these  substances  can  be  used,  because  they  disagree  with  the  pa- 
tient, producing  dryness  of  the  parts  or  increasing  the  inflammation. 
In  such  cases  we  must  carefully  search  for  the  right  local  remedy.  We 
may  find  it  in  tannin,  tincture  of  the  chloride  of  iron,  astringent  de- 
coctions, nitrate  of  silver  in  solution,  etc.  The  last,  used  once  in  four 
or  five  days,  with  a  glass  syringe,  and  the  other  astringents  between, 
often  proves  to  be  the  best  course. 

An  excellent  and  very  convenient  mode  of  applying  medicinal  sub- 
stances to  vaginal  surfaces  is  to  make  small  sacs  of  gauze  or  linen,  and 


248  AFFECTIONS    OF   THE    VAGINA. 

fill  them  with  the  substance  intended  for  use,  and  introduce  them 
into  the  vagina.  A  sac  the  size  of  a  small  glove  finger,  with  a  piece  of 
thread  attached  to  it,  will  hold  an  abundance  of  almost  any  remedy 
we  desire  to  use.  Tannin  in  powder  or  ointment,  gall  ointment,  bella- 
donna ointment,  and  other  articles  are  used  in  this  way.  A  mixture 
I  have  used  very  commonly  consists  of  two  drops  of  creasote,  half 
drachm  of  tannin,  and  one  grain  of  belladonna  extract,  introduced  at 
bedtime  each  night.  The  little  bag  may  be  removed  in  the  morning 
by  traction  on  the  string.  There  are,  I  think,  some  advantages  in  the 
use  of  these  little  bags  over  the  other  sorts  of  medicated  pessaries  used. 
I  not  unfrequently  inclose  copaiba  capsules  in  these  little  sacs,  and 
think  it  an  admirable  mode  of  making  balsamic  applications  to  the 
vaginal  mucous  membrane.  Where  the  astringents  or  other  remedies 
are  thus  used  they  will  not  replace  the  injections  wholly.  Indeed, the 
vagina  should  be  well  washed  out  before  the  introduction  and  at  the 
time  of  the  removal  of  them.  Patients,  of  course,  can  manage  these 
applications  without  aid. 

Perseverance  and  time  are  important  items  in  the  treatment.  If  we 
can  remove  this  chronic  inflammation  in  three  or  even  six  months,  we 
ought  to  be  satisfied.  And  we  ought  not  to  be  surprised  to  have  it  re- 
turn once,  or  more  times,  after  it  is  apparently  cured.  It  is  well,  also, 
to  teach  our  patient  patience  in  this  respect. 

Puerperal  Vaginitis. 

It  might  not  seem  necessary  to  consider  the  vaginitis  occurring  after 
labor  as  a  separate  affection,  but  there  is  so  much  difference — in  the 
causes,  nature,  symptoms,  and  termination — between  ordinary  vagi- 
nitis and  this  form  that  I  think  it  may  be  profitable  to  do  so.  In  some 
cases  of  labor,  circumstances  occur  that  induce  a  severe  form  of  in- 
flammation of  the  vagina.  The  one  most  j^otent  is  long  detention  of 
the  fetal  head  in  the  pelvis.  The  pressure  thus  exercised  upon  the 
vaginal  walls  interupts  the  circulation  more  or  less  completely;  and 
if  continued  for  a  number  of  hours,  violent  reaction  in  the  parts 
results  when  the  pressure  is  removed.  This  pressure  does  not  affect 
the  mucous  membrane  of  the  vagina  so  deleteriously  as  the  deeper  seated 
tissues.  The  fibro-cellular  part  of  the  vaginal  walls  is  the  seat  of  the 
inflammation.  I  do  not  think  the  use  of  instruments,  however  awk- 
wardly, does  so  much  damage  as  the  long-continued  pressure.  It  must 
not  be  denied,  however,  that  instruments  do  give  origin  to  this  form  of 
inflammation.  When  they  do  so,  the  inflammation  is  more  circum- 
scribed ;  it  does  not  extend  to  all  parts  of  the  vagina,  as  is  apt  to  be 
the  case  when  pressure  by  the  child's  head  has  been  the  cause.  On 
account  of  the  nature  of  the  causes,  this  form  of  vaginitis  runs  its 
course  rapidly,  and  is  most  sure  to  end  in  structural  lesions.     It  is  in 


PUERPERAL   VAGINITIS.  249 

intense  forms  of  this  sort  of  vaginal  inflammation  that  sloughs  and 
deep  ulcerations  are  met  with,  which  open  the  bladder  and  cause  vesico- 
vaginal fistula,  recto-vaginal  fistula,  and  cicatrices  which  result  in  con- 
tractions and  even  occlusions  of  the  vagina.  It  is  astonishing  how 
much  destruction  is  sometimes  effected  by  intense  post-partum  inflam- 
mation. I  remember  being  called  to  a  case,  in  consultation,  where  the 
child's  head  had  been  pressing  down  sufficient  to  bulge  the  perineum 
and  labia  for  sixty  hours  without  any  movement.  I  delivered  her  with 
the  short  forceps  in  a  few  moments,  without  any  violence  to  the  parts. 
The  patient  was  then  unavoidably  left  in  the  hands  of  the  same  care- 
less practitioner  that  had  so  outrageously  neglected  her  before  the 
delivery.  I  saw  her  three  months  afterwards,  and  found  the  whole 
septum  between  the  bladder  and  vagina  gone,  the  urethra  terminating 
abruptly,  as  though  it  had  been  cut  straight  across,  in  a  great  irregular 
cavity,  that  was  bounded  by  the  pubis  before  and  the  uterus  behind, 
and  without  any  defined  sides  to  it.  In  still  a  worse  case,  where 
shoulder  presentation  had  prevented  the  passage  of  the  child,  the 
woman  was  in  the  second  stage  of  labor  six  days.  The  woman  arose 
from  her  bed  with  a  large  undefinable  cavity, — without  any  bladder, 
apparently,  but  the  very  top  portion, — and  the  loss  of  two  inches  of 
rectum,  into  which  the  urine  and  fseces  were  poured  involuntarily.  In 
more  than  one  instance  I  have  seen  the  whole  vagina  sealed  up,  from 
the  fourchette  to  the  urethra,  and, — as  far  as  lean  judge, — to  the  os 
uteri,  as  the  effect  of  intense  and  neglected  puerperal  vaginitis,  arising 
from  unaided  difficult  labor.  Every  practitioner  must  meet  with  cases 
in  which  the  cavity  of  the  vagina  is  misshaped,  and  partially  closed, 
from  the  cicatrices  resulting  from  it.  Now,  much  of  these  direful 
effects  may  be  averted  by  the  rational  management  of  inflammation 
after  it  has  been  initiated. 

Symptoms. 

When  injurious  pressure  has  awakened  inflammation  in  the  vagina, 
the  labia  and  walls  become  swollen,  hot,  and  very  tender.  The 
patient  does  not  generally  complain  of  mxuch  severe  pain,  but  there  is 
a  sense  of  soreness  and  heat.  There  is  almost  always  fever,  chilliness, 
and  other  evidences  of  disturbances  of  the  circulation ;  the  tongue  is 
coated,  ordinarily  white,  sometimes  yellow,  or  even  brown,  from  the 
beginning.  As  the  disease  advances,  two  or  three  days  from  the  begin- 
ning, the  discharge  from  the  vagina  becomes  more  than  ordinarily  fetid, 
the  labia  excoriated,  while  the  heat  of  the  vagina  is  still  very  great, 
and  there  is  much  mucus  and  some  pus  issuing  from  it ;  and  later, 
shreds  of  decomposed  substances,  and  sometimes  considerable  sloughs, 
are  mingled  with  the  discharge,  increasing  the  fetor.  The  pulse  is 
more  accelerated,  and  sometimes  becomes  quite  rapid ;  the  patient  is 
much  prostrated ;  the  tongue  brown  and  dry,  and  the  teeth  foul  with 


250  AFFECTIONS   OF   THE   VAGINA. 

a  dark  clammy  mucus,  while  the  skin  is  bathed  in  a  copious  perspira- 
tion. In  from  two  to  six  or  eight  days,  to  these  symptoms  is  added 
an  evacuation  of  urine  through  the  vagina,  at  first  small  quantities, 
and  afterwards  more  considerable,  until,  in  a  short  time,  the  contents 
of  the  bladder  are  passed  in  this  way  ;  the  parts  around  are  excoriated 
by  the  urine  and  other  acrid  discharges,  and  a  slow,  uncertain  con- 
valescence succeeds,  with  a  permanent  vesico-vaginal  fistula.  Occa- 
sionally, though  not  so  frequently,  the  fseces  pass  through  the  vagina 
a  fcAV  days  after  the  beginning  of  the  inflammation,  and  we  have  a 
recto-vaginal  fistula.  If  neither  of  these  evils  occur,  there  is  extensive 
ulceration,  not  so  deep,  but  extending  over  a  large  surface  of  the 
vagina ;  thus  pus  and  acrid  ichor  are  poured  out  in  copious  quanti- 
ties, for  a  long  time,  gradually  decreasing  as  the  surface  heals.  As 
these  ulcerations  heal  up,  the  tissue  becomes  condensed  and  contracted, 
until  such  strictures  or  occlusions  result  as  are  above  mentioned.  The 
practitioner  should  be  wide  awake  to  this  frequent  course  of  post- 
partum vaginitis. 

Treatment. 

As  most  damage  from  this  form  of  vaginitis  usually  accrues  to  the 
bladder  and  rectum,  our  first  and  most  solicitous  care  should  be  be- 
stowed upon  them.  The  bladder  should  be  frequently  emptied  with 
the  catheter ;  at  least  every  few  hours  the  urine  must  be  drawn  off. 
To  appreciate  this  direction,  we  have  but  to  remember  that  this  organ 
may  be  considerably  distended  in  that  time,  and  as  the  septum  between 
the  vagina  and  bladder  is  in  a  state  of  intense  inflammation,  it  is  soft- 
ened, and  therefore  is  easily  ruptured.  My  impression  is  that  fifty 
per  cent,  of  the  vesico-vaginal  fistulse  which  now  occur  might  be 
avoided  by  following  this  rule.  Its  importance  cannot  be  overestimated. 
In  very  bad  cases  the  catheter  might  be  used  even  more  frequently, 
or  kept  in  the  urethra.  The  rectum  should  be  kept  free  from  any 
accumulation  of  fseces  by  frequent  injections  of  tepid  water.  In  addi- 
tion to  this  prevention  of  fistula,  the  utmost  cleanliness  must  be  ob- 
served. The  vagina  should  be  washed  out  with  soapsuds  or  other 
bland  detergent  fluid,  from  four  to  six  times  a  day.  For  the  first  four 
or  five  days  the  parts  ma}^  be  kept  lubricated  thoroughly  by  the  injec- 
tion, after  the  water,  of  very  bland  sweet  oil,  or  almond  oil.  When 
the  slough  begins  to  be  thrown  off,  or  pus  and  sanies  become  copious, 
an  injection  of  half  a  pint  of  tepid  water,  containing  six  or  eight  drops 
of  creasote,  twice  a  day,  will  serve  to  cleanse  and  stimulate  the  parts 
better  than  soap  and  water  alone,  which  should  be  used  between  times. 
After  the  lapse  of  a  week  or  ten  days,  if  the  ulceration  is  not  healing, 
an  injection  of  ten  grains  of  nitrate  of  silver  to  the  ounce  of  water 
may  be  used  quite  advantageously.  This  solution  should  be  injected 
from  a  hard  rubber  or  glass  syringe,  directed  to  the  ulcerated  part  by 


URINARY   FISTULA. 


251 


the  finger.  As  the  case  still  further  advances,  a  solution  of  tannin, 
alum,  sulphate  of  zinc,  or  other  astringents,  with  the  detergents,  may 
be  used.  As  the  parts  begin  to  contract  by  the  advanced  healing  of 
the  ulceration,  the  closure,  partial  or  entire,  should  be  anticipated  by 
the  introduction,  daily  or  oftener,  of  wax,  rubber,  or  other  sort  of 
bougies.  It  is  well,  when  this  last  expedient  is  necessary,  to  smear 
them  with  ointment  that  may  exert  a  healing  influence  on  the  ulcera- 
tion. The  physician  cannot  be  too  attentive  to  these  cases.  He  should 
see  to  it  personally  that  his  directions  are  carried  out,  and  feel  himself 
responsible  for  any  serious  permanent  injury  that  can  result  from  want 
of  diligence.  Women  or  their  nurses  cannot  understand,  and  it  is 
feared  that  physicians  do  not  properly  appreciate,  the  means  of  avert- 
ing the  awful  accidents  which  result  from  sloughing  and  ulceration  in 
these  cases. 

Urinary  Fistula. 

Although  generally  resulting  from  puerperal  vaginitis,  fistula  is 
sometimes  produced  by  other  causes.  Extensive  ulcerations  from 
pessaries  sometimes  penetrate  the  septum  between  the  vagina  and 


Fig.  163. 


Fig.  164. 


bladder.  Stone  or  other  foreign  bodies  in  the  bladder  may  act  as 
causes  of  ulcerative  processes  of  sufficient  gravity  to  do  the  same. 
Malignant  diseases,  as  cancer  of  the  uterus,  vagina,  or  bladder,  not 
unfrequently  lay  open  these  cavities;  and,  in  some  rare  instances, 
perforations  by  the  unskilful  use  of  instruments  have  been  observed. 


252  AFFECTIONS    OF   THE    VAGINA. 

Urinary  fistula naay  be:  first, urethro-vaginal;  second, vesico-vaginal; 
third,  vesico-uterine;  and,  fourth,  vesico-utero-vaginaL  In  the  first 
variety  the  opening  is  through  the  urethra ;  in  the  second  through  the 
septum  between  the  vagina  and  bladder;  in  the  third  the  vesical  wall 
of  the  cervix  uteri  is  perforated;  in  the  fourth,  two  cases  of  which  I 
have  seen,  the  anterior  and  posterior  portions  of  the  cervix  are  both 
laid  open.  The  cervix  is  sometimes  involved  with  the  vaginal  septum, 
being  torn  up  from  the  extremity  through  the  anterior  lip  into  the 
vaginal  cavity.  The  whole  urethra  sometimes  sloughs  off",  leaving  the 
pubic  arch  unoccupied  by  that  canal.  In  one  case  I  have  recently 
seen,  the  urethra  and  neck  of  the  bladder  were  lost,  leaving  the  re- 
mainder of  the  vesico-vaginal  septum  healthy  and  entire.  In  certain 
other  instances  the  whole  lower  portion  of  the  bladder  is  wanting,  and 
the  uterus  more  or  less  mutilated.  To  make  the  condition  more 
deplorable,  in  some  rare  examples  of  the  terrible  destruction  of  the 
parts,  the  rectum  is  involved  in  the  common  ruin.  The  size  of  the 
opening  in  the  urethra  or  vesico-vaginal  septum  is  sometimes  so  small 
as  scarcely  to  be  perceptible,  and  from  this  it  ma^^  vary  through  all 
grades  of  dimension  to  the  irreparable  loss  of  tissue  above  described. 
The  direction  may  be  lengthwise,  diagonal,  tortuous,  or  crosswise. 

The  fistula,  when  established,  is  usually  associated  with  other  effects 
of  the  disease  from  which  it  is  produced.  Cicatrices  and  contractions 
of  the  vaginal  walls  are  very  common  accompaniments.  These,  when 
extensive,  embarrass  examinations  and  operations  very  much.  They 
also  change  the  size,  shape,  and  direction  of  the  vaginal  cavity. 

Diagnosis. 

The  constant  flow  of  urine  through  the  vagina,  instead  of  the 
urethra,  is  a  sufficient  symptom  to  decide  the  existence  of  fistula ;  but 
we  meet  with  cases  where  the  flow  of  urine  is  not  constant,  the  patient 
being  able  to  retain  for  some  time  and  then  discharge  her  urine  natu- 
rally. This  circumstance  is  due  to  the  plugging  of  a  small  opening 
by  mucus,  or  the  prolapse  of  some  part  of  the  bladder  into  the  fistula. 
In  all  instances  it  is  jaroper  and  necessary  to  make  a  clear  diagnosis 
of  the  existence,  size,  shape,  position,  and  complications  of  the  fistula. 
This  is  usually  easily  done  by  the  fingers  and  probe.  The  patient 
should  lie  on  her  back  with  her  hips  near  the  edge  of  the  bed,  and 
her  legs  flexed  so  that  we  may  have  free  use  of  both  hands.  The 
fingers  will  readily  pass  through  a  large  fistula  into  the  bladder,  and, 
by  moderate  care,  be  made  to  thoroughly  survey  it  and  the  surround- 
ing parts.  But  the  fistula  may  be  so  small  or  situated  so  as  to  entirely 
escape  detection  by  the  finger.  We  shall  be  aided  in  such  cases  by 
introducing  a  probe,  slightly  bent,  through  the  urethra  with  one 
hand,  while  the   fingers  of  the  other  are  in  the  vagina.     The  bent 


URINARY    FISTULA.  253 

extremity  of  the  probe  is  turned  toward  the  septum,  jaressed  gently 
upon  and  passed  over  every  part  of  it  until  it  is  made  to  pass  through 
the  opening,  when  it  may  be  recognized  by  the  finger  in  the  vagina. 
When  the  perforation  is  very  small,  or  vesico-uterine,  this  kind  of 
examination  will  fail  to  find  it.  In  such  cases  the  vagina  should  be 
dilated  as  for  operation,  and  exposed  in  a  good  light  so  that  every 
portion  may  be  seen.  When  thus  exposed,  the  cavity  should  be 
sponged  out  and  all  the  urine  thus  removed.  After  this  perforation, 
usually,  we  have  but  to  watch  a  few  moments  when  we  shall  perceive 
the  fluid  making  its  appearance  through  a  minute  pore,  which,  per- 
haps, is  hidden  in  an  ulcer  in  some  remote  part,  or  we  may  observe 
it  coming  through  the  os  uteri.  If,  however,  no  urine  makes  its  way 
through  in  such  quantity  as  to  indicate  the  place  of  injury,  we  may 
inject  the  bladder  with  tepid  water  in  such  amount  as  to  distend  the 
organ  somewhat.  Soon  the  obstacle  is  overcome  and  the  water 
will  escape  copiously  into  the  vagina.  If  it  comes  through  the  mouth 
of  the  uterus,  the  fistula  is  situated  in  the  cervical  cavity.  This  may 
be  made  more  conclusive  by  plugging  the  os  with  cotton  and  again 
injecting  the  bladder.  The  fluid  will  not  escape,  of  course,  until  the 
cotton  is  removed,  when  it  will  pass  in  such  abundance  as  to  leave  no 
doubt  of  its  place  of  exit.  German  physicians,  Veit  especially,  recom- 
mend the  use  of  water  colored  so  as  to  make  its  flow  through  the  open- 
ing more  obvious. 

Prognosis. 

Having  found  the  fistula,  ascertained  its  size,  position,  shape,  direc- 
tion, etc.,  we  ought  to  survey  the  vagina,  to  find  strictures  or  other 
deformity,  and  ascertain  the  distensibility  of  this  tube.  We  do  this 
in  part  to  determine  the  prognosis  of  the  case.  Can  the  fistula  be 
cured?  is  a  pertinent  and  important  question,  which  will  be  decided 
by  this  kind  of  examination.  Fortunately,  noiv,  thanks  to  Dr.  Sims, 
almost  anything  short  of  loss  of  the  whole  septum  may  be  cured.  If 
the  fistula  consists  of  a  defined  opening,  it  matters  little  how  large,  we 
are  justified  in  expecting  success.  If,  as  is  sometimes  the  case,  there 
are  no  sides,  edges,  or  ends  to  it,  but  the  vagina  and  bladder  are  one 
cavity,  smooth,  and  continuous,  we  cannot  reasonably  undertake  an 
operation  unless  it  be  to  close  the  vulva,  as  has  been  suggested  and 
practiced.  Some  circumstances,  independent  of  the  character  and 
size  of  the  fistula,  are  necessary  to  insure  success.  The  vagina  should 
be  healthy.  If  the  walls  of  this  cavity  are  in  a  state  of  inflammation 
or  congestion,  the  prospects  of  a  cure  are  more  remote.  Great  nervous 
susceptibility  is  sometimes  difficult  to  overcome,  and  should  be  a 
reason  to  defer  the  operation.  The  general  health  of  the  patient  is 
also  a  matter  of  the  first  importance.  A  highly  nervous  condition  of 
the  system,  with  an  abundance  of  lithates  in  the  urine,  is  a  condition 
in  which  there  are  many  chances  of  failure. 


254  AFFECTIONS    OP   THE    VAGINA. 


Treatment 


Naturally  divides  itself  into  palliative  and  curative. 

The  palliative  treatment  is  of  great  importance,  and  he  would  be  a 
benefactor  who  should  devise  means  of  preventing  the  great  suffering 
which  results  from  these  inevitable  circumstances.  The  greatest 
amount  of  pain  and  suffering  in  such  cases  is  caused  by  the  flow  of 
urine  over  the  cutaneous  surface.  The  salts  held  in  solution  by  the 
urine,  and  the  compounds  resulting  from  their  chemical  decomposition 
inflame  and  excoriate  the  skin  of  the  thighs,  perineum,  and  external 
genital  organs.  Relief  can  be  perfect  only  by  preventing  the  contact 
of  the  urine  with  the  skin.  I  think  there  would  be  little  difficulty  in 
making  an  instrument  that  would  collect  the  urine,  in  most  cases, 
before  being  discharged  from  the  vagina.  But  the  difficult}^  consists 
in  getting  one  that  would  be  tolerated  in  the  parts.  What  we  want  is 
a  sac  that  may  be  introduced  and  retained  in  the  vagina  with  an 
opening  in  the  upper  wall  opposite  the  fistula,  large  enough  to  i3ermit 
the  urine  to  flow  into  it.  The  sac  should  have  a  tube  leading  out  of 
the  vaginal  orifice  in  order  to  convey  the  urine  into  a  reservoir  outside, 
which  should  be  attached  to  the  person  of  the  patient.  The  sac  should 
be  of  india-rubber  or  other  impervious  material,  and  so  soft  and  smooth 
as  not  to  irritate  the  mucous  membrane  of  the  vagina,  and  so  small  as 
not  to  distend  the  vagina  painfully.  But  the  urine  would  not  flow  into 
and  through  this  tube  unless  the  sac  was  distended  so  that  the  opening 
is  applied  to  the  fistula.  The  distension  may  be  eflPected  sufficiently 
after  the  sac  is  introduced,  by  passing  cotton  up  through  the  tube.  In 
order  to  make  the  urine  drain  through  the  tube  something  like  cancel- 
larise  should  extend  from  the  cotton  in  the  sac  outside  through  the 
tube.  The  drainage  will  be  started  by  wetting  the  contained  material. 
By  capillary  attraction  the  cotton  absorbs  the  urine  until  it  becomes 
saturated,  while  the  loose  cord  will  carry  it  off  like  a  siphon  through 
the  tube.  If  an  instrument  of  this  kind  can  be  made  that  will  be 
tolerated  by  the  vagina,  I  think  it  will  act  well. 

In  the  absence  of  anything  to  prevent  the  urine  from  flowing  on  the 
person,  the  patient  must  depend  upon  frequent  ablution  with  warm 
water  externally,  and  upon  warm  injections  in  the  vagina.  After 
washing  externally,  the  skin  should  be  kept  covered  with  simple  oint- 
ment. The  injections  should  be  made  four  or  five  times  in  the  twenty- 
four  hours,  and  the  external  ablutions  as  often  as  the  napkins  become 
sufficiently  saturated  to  replace  by  others. 

Another  item  in  the  palliative  management  of  the  first  importance 
is  one  mentioned  by  Dr.  T.  A.  Emmet,  viz.,  never  to  use  a  napkin  twice 
without  washing.  Sometimes  to  avoid  labor  patients  will  simply  dry 
the  napkins  and  then  use  them  again,  thus  using  a  napkin  several 
times  without  washing.  In  this  way  the  salts  of  the  urine  are  applied 
to  the  skin  in  double  strength,  and  the  mischief  greatly  increased. 


UEINAEY   FISTULA.  255 

The  curative  treatmsnt  consists  in  the  closure  of  the  fistula. 

It  is  hardly  necessary  to  mention  any  other  method  than  the  closure 
of  the  fistula  by  suture  in  some  form  or  other.  Cauterization  was  often 
resorted  to  before  the  present  safe  and  sure  plans  of  operation  by  Drs. 
Sims  and  Bozeman,  but  is  now  scarcely  thought  of. 

To  Dr.  J.  Marion  Sims  we  are  indebted  for  the  cure  of  vesico-vaginal 
fistula ;  for  although  others  had  succeeded  in  making  cures  by  the  use 
of  nearly  the  same  means,  his  ingenuity  and  persevering  industry  gave 
such  positiveness  and  intelligent  definiteness  to  the  different  steps  to  be 
followed  in  order  to  succeed,  as  to  convert  the  operation  from  one  of 
great  uncertainty,  confined  to  experts  and  experienced  operators,  to  an 
easy,  almost  invariably  successful  one,  which  any  surgeon  of  ordinary 
skill  may  venture  upon  without  fear  of  failure.  The  profession  is 
also  indebted  to  Dr.  T.  A.  Emmet,  for  a  very  lucid  demonstration  of 
the  principles  upon  which  the  operation  is  founded,  in  his  work  on 
that  subject. 

In  describing  the  very  simple  operation  of  Dr.  Sims  one  can  scarcely 
do  otherwise  than  follow,  if  not  copy,  the  graphic  description  given  by 
Dr.  Emmet.  Very  much  depends  upon  proper  preparation  of  the 
system  of  the  patient  and  the  parts  concerned,  in  order  to  insure  suc- 
cessful adhesion  of  the  two  edges  of  the  fistula.  The  patient  should 
be  in  the  best  possible  general  health.  I  think  there  is  great  propriety 
in  the  distinction  insisted  upon  by  some  surgeons  between  the  plastic 
and  aplastic  diathesis  in  patients  subjected  to  surgical  operations,  and 
am  anxious  that  my  patients,  for  some  weeks  before  the  operation,  be 
subjected  to  the  best  hygienic  conditions  for  their  general  health.  In 
the  country,  if  possible,  plenty  of  exercise  in  the  open  air,  good  nutri- 
tious diet,  a  contented  and  happy  state  of  mind  are  all  that  are  required 
to  effect  the  desired  preparatory  condition.  In  patients  whose  blood 
is  impoverished  from  nursing,  hemorrhages  or  other  debilitating  cir- 
cumstances, the  ferruginous  and  bitter  tonics  should  be  administered. 
If  the  general  health  is  well  established  and  maintained  for  a  little 
time,  the  vagina  will  scarcely  be  otherwise  than  firm  and  sound  in 
texture,  and  free  from  the  troublesome  urinary  concretions  that  some- 
times adhere  to  the  mucous  membrane  of  the  vagina,  the  vulva,  and 
even  the  greater  labia.  During  the  preparatory  constitutional  treat- 
ment, where  that  is  necessary,  the  local  preparation  may  be  attended 
to — by  frequent  cleansing  by  copious  injections  of  warm  water,  stimu- 
lating the  parts  in  the  vagina  that  are  red  or  excoriated  with  a  weak 
solution  of  nitrate  of  silver  every  four  or  five  days.  The  solution  may 
be  of  the  strength  of  5j  to  f.?iv  of  distilled  water.  Dr.  Emmet  says 
that : 

"  It  is  frequently  necessary  to  pursue  the  same  general  course  for  many  weeks  before 
the  parts  can  be  brought  into  a  perfectly  healthy  condition.  This  point  is  not  reached 
until  not  only  the  vaginal  wall,  but  also  the  hypertrophied  and  indurated  edges  of  the 


256 


AFFECTIONS   OF   THE  VAGINA. 


fistula  have  attained  a  natural  color  and  density.  This  is  the  secret  of  success,  but  the 
necessity  is  rarely  appreciated  ;  without  which  the  most  skilfully  performed  operation 
is  almost  certain  to  fail." 

The  only  other  preparatory  step  will  be  the  administration  of  a 
cathartic  to  evacuate  the  bowels.  The  catharsis  ought  to  be  entirely 
over  at  least  twelve  hours  before  the  operation.  With  these  prelimi- 
naries accomplished,  we  should  have  a  large  window  on  the  sunny 


Fig.  165. 


Fig.  166. 


Fig.  167. 


\ 


Fig.  165.— Tenaculum,  with  which  to  hold  the  edge  of  Fistula  while  being  pared. 
Fig.  166.— Curved  Scissors,  for  paring  edge  of  Fistula. 
Fig.  167,— Wire  Adjuster. 

side  of  the  house,  a  sun-shining  day,  four  assistants,  a  table  of  conve- 
nient height,  five  feet  long  and  two  wide,  and  the  necessary  instru- 
ments. The  table,  covered  with  one  or  two  quilts,  is  to  be  placed  with 
the  end  toward  the  window,  from  four  to  six  feet  distant.  The  patient 
lies  on  her  left  side,  the  limbs  drawn  up,  the  right  a  little  more  than  the 
left  with  the  left  arm  behind  her,  so  that  she  rests  full  on  the  front  of 
the  chest.     One  of  the  four  assistants  uses  the  anaesthetic,  another  the 


URINARY    FISTULA. 


257 


speculum,  a  third  the  sponges,  and  the  fourth  attends  to  the  instru- 
ments.    The   instruments  should  he  placed  on  a  tray,  within  easy 


Fig.  168. 


Fig.  168.— Speculum  for  dilating  Vagina. 

Fig.  169.— Forceps  for  twisting  the  Wires. 

Fig.  170.— The  Catheter. 

Fig.  171.— Needle  Forceps. 

Fig.  172.— Sponge-hold  jr.  The  instruments  are  represented  half  size. 

reach  of  the  operator.     They  are  the  speculum,  two  tenacula,  scissors, 
Emmet   knife,   two    long   sponge-holders,    forceps   for   carrying   the 

17 


258 


AFFECTIONS    OF    THE    VAGINA. 


needles,  one  wire  adjuster,  a  blunt  hook,  forceps  to  twist  the  wire, 
half  a  dozen  needles,  slightly  curved,  about  one  inch  long,  armed 
with  silk  hgature,  doubled  so  that  the  silver  wire  may  be  placed  in 
the  loop  and  thus  drawn  through  the  wound,  an  elastic  male  catheter, 
or  one  of  Sims's  S-shaped  instruments,  with  an  india-rubber  tube,  a 
little  larger  than  the  catheter,  to  carry  the  urine  clear  of  the  bed. 
The  surgeon  takes  his  seat  at  the  end  of  the  table  next  the  window, 
near  the  breech  of  the  patient,  introduces  the  speculum,  dilates  the 


Fig.  17 


Fig.  174. 


Method  of  paring  the  Edges. 


Method  of  passing  the  Needle. 


vagina,  and  thus  brings  the  parts  thoroughly  in  view,  and  then  gives 
the  instrument  to  the  assistant  to  keep  in  that  position.  If  the  posi- 
tion of  the  patient  prevents  the  parts  from  being  thoroughly  exposed 
and  lighted,  it  should  be  changed  until  this  difficulty  is  obviated, 
when  the  operator  may  proceed  as  follows:  With  the  tenaculum  in  the 
left  hand,  the  edge  of  the  fistula  is  transfixed  and  held  up  to  view,  and, 
with  the  scissors,  bevelled  from  the  mucous  membrane  of  the  bladder 
outward.  Dr.  Emmet  says  the  point  of  the  tenaculum  should  be  in- 
troduced toward  the  fistula,  as  shown  in  the  figure.     As  much  as  prac- 


URINARY    FISTULA. 


259 


ticable  should  be  removed  in  this  way,  without  changing  the  place  of 
the  tenaculum.  Another  23lace  on  the  edge  of  the  fistula  is  then  seized 
and  trimmed  in  the  same  manner,  and  so  on,  until  the  whole  circle 
is  denuded  completely  of  the  cicatricial  tissue.  We  may  sometimes 
succeed  after  a  little  practice  in  removing  a  complete  ring  of  the  edge 
of  the  fistula.  This  will,  of  course,  insure  to  us  a  more  perfect  opera- 
tion than  if  the  parts  are  removed  in  pieces.  As  this  part  of  the 
operation,  is  being  accomplished,  the  assistance  of  the  sponge  will  be 
required  on  account  of  the  bleeding.  I  do  not  see  the  necessity  of 
removing  as  much  substance  from  the  edge  of  the  fistula  as  is  directed 
by  some  authors. 

The  main  object,  I  think,  is  to  have  the  edges  evenly  and  thoroughly 
denuded  of  the  mucous  membrane.     This  much  should  be  done  with 

Fig.  175. 


Method  of  using  the  Tenaculum  in  giving  aid  to  the  Needle. 


a  completeness  that  admits  of  no  doubt,  and  if  we  have  a  good  light, 
there  need  be  no  doubt,  as  we  can  see  and  examine  the  part  suffi- 
ciently well  to  be  positive.  After  the  bleeding  has  ceased,  we  may 
insert  the  sutures.  We  commence  at  the  angle  of  the  wound  most 
remote  and  difficult  to  reach.  The  needle  is  to  be  introduced  first 
into  the  lip  of  the  wound  nearest  to  the  operator,  by  starting  it  in 
about  half  an  inch  from  the  freshened  edge,  dipping  it  down,  so  as 
to  make  the  point  come  out  in  the  denuded  portion,  just  at  the  junc- 
tion of  it  and  the  vesical  mucous  membrane.  The  needle  being 
brought  through  at  this  point,  is  again  inserted  in  the  opposite  edge, 
corresponding  as  near  as  possible  with  that  part  whence  it  emerged, 


260 


AFFECTIONS    OF   THE   VAGINA. 


and  carried  forward  far  enough  to  emerge  half  an  inch  beyond  the 
edge  of  the  wound,  and  drawn  through;  the  wire  is  then  hooked  in 
the  double  end  of  the  silk  and  drawn  through  the  wound,  and  de- 
tached from  the  silk  and  given  to  the  assistant  in  charge  of  the 
speculum  to  retain  in  its  place.  The  next  suture  is  to  correspond 
with  and  be  placed  within  two  lines  of  the  first.  They  are  thus 
placed  in  sufficient  numbers  to  close  the  opening  completely.  (See  Fig. 
176.)  Having  all  the  sutures  introduced,  the  one  nearest  the  operator 
must  be  isolated  and  twisted  by  the  forceps  made  for  that  purpose, 


^^W 


The  Fistula  with  Edge  Pared  and  the  Sutures  Placed. 

until  the  angle  of  the  wound  is  evenly  coaptated.  The  next  is  to  be 
managed  in  the  same  way,  and  so  of  the  remainder  in  order.  Great 
care  must  be  taken  to  see,  as  the  closure  is  effected,  that  the  lips  of 
the  wound  are  drawn  evenly  and  smoothly  together.  (See  Fig.  177.) 
If  we  are  not  particular,  the  edge  of  one  side  or  the  other  rolls  slightly 
in  and  unrefreshened  mucous  membrane  is  brought  up  to  the  denuded 
surface.  This,  I  think,  is  a  circumstance  that  is  very  liable  to  occur 
in  the  hands  of  an  inexperienced  operator.  Both  the  insertion  of  the 
sutures  and  bringing  together  the  edges  may  be  facilitated  by  the 
skilful  use  of  the  tenaculum  and  the  adjuster.     The  tenaculum  will 


URINARY    FISTULA. 


261 


enable  us  to  disengage  and  straighten  the  edges,  iii  adjusting  them, 
and  keep  them  firm  in  inserting  the  needles.  The  adjuster  will  place 
the  twist  of  the  wire  in  any  position  we  may  desire  with  reference  to 
the  junction  of  the  wound.  In  twisting  the  wire  there  are  two  things 
to  be  avoided, — one  is  tightening  it  too  much,  and  the  other  leaving  it 
too  lax.  Experience  will  fix  these  items  after  a  few  operations,  but  I 
think  that  the  operator  may  venture  to  tighten  the  twist  of  the  wire 
UDtil  it  fixes  but  does  not  strangulate  the  part  included  in  the  stitch. 
After  the  twist  is  completed,  we  ought  to  be  able  to  pass  an  ordinary 
probe  through  the  circle  of  the  stitch  without  much  force,  and  yet, 
upon  its  removal,  there  should  be  no  apparent  space.  If  the  stitch  is 
drawn  too  tightly,  the  j)arts  will  be  strangulated  and  early  cut  through 

Fig.  177. 


Wire  Adjuster.- 

by  ulceration ;  if  too  loose,  the  urine  will  pass  through  as  the  bladder 
becomes  filled  and  prevent  adhesion. 

As  each  wire  is.  adjusted  and  twisted  it  should  be  bent  over  the 
tenaculum,  so  as  to  lie  flat  upon  the  surface  of  the  mucous  membrane 
of  the  vagina.  The  operation  finished,  the  catheter  may  be  inserted, 
the  patient  placed  carefully  in  bed,  on  either  side,  and  a  grain  of 
opium  administered.  The  catheter  will  sometimes  become  foul  with 
deposits,  and  require  cleaning  every  twelve  or  eighteen  hours,  but  as 
a  rule,  while  the  urine  is  running  freely,  it  may  remain  in  place. 
Great  watchfulness  will  alone  prevent  this  instrument  from  being 
misplaced.  The  great  desiderata  of  the  after-treatment,  are  to  pre- 
vent an  accumulation  of  urine  in  the  bladder,  and  the  bowels  from 
being  evacuated.     The  former  can  be  certainly  accomjolished  in  no 


262 


AFFECTIOXS    OF    THE   Y  AGIN  A. 


other  way  than  by  having  a  competent  assistant  by  the  patient,  or 
very  near  her  all  the  time,  who,  when  the  catheter  does  not  deliver 
the  water  freely,  will  remove  it  and  replace  a  clean  one,  however 
frequently  that  may  be  required.  Dr.  Emmet  directs  that  the  patient 
be  placed  upon  her  back  and  so  remain  during  the  after-treatment. 
He  causes  a  double  inclined  plane  to  be  made  by  the  bedding,  so  that 
the  legs  may  be  bent  and  the  head  and  shoulders  elevated.  We  may 
keep  the  bowels  quiet  by  administering  a  grain  of  opium  twice  or 
three  times  a  day.  If  the  patient  is  very  restless,  we  ought  to  give  as 
much  more  as  is  necessary  to  quiet  her.     The  only  other  important 


Fig.  178. 


Fig.  179. 


Closing  the  Wounds  and  Twisting  the  Wire  Sutures. 


Removing  the  Sutures. 


item  of  treatment  as  a  general  thing  is  cleanliness,  and  for  this  pur- 
pose vaginal  injections  of  tepid  water,  with  fine  toilet  soap,  twice 
or  three  times  a  day,  will  suffice.  The  vagina  will  thus  be  kept  clean 
with  much  certainty.  The  diet  should  not  be  too  sparing.  The 
ordinary  diet  of  the  patient,  in  half  or  two-thirds  of  the  quantity,  I  am 
convinced,  is  better  than  any  considerable  change  in  quality.  The 
patient  must  remain  quiet  as  practicable  for  nine  or  ten  days.  There 
will  be  no  good  in  leaving  the  sutures  in  place  longer  than  ten  days 
perhaps,  but  there  can  no  harm  result  from  their  longer  presence. 
The  removal  of  them  is  easily  accomplished,  by  passing  one  blade  of 
the  scissors  within  the  circle  of  the  stitch,  and  dividing  it,  when  the 
wire  may  be  withdrawn  by  the  forceps.     The  patient  should  keep 


URINARY    FISTULA. 


263 


her  position  and  wear  the  catheter  for  five  or  six  days,  after  the 
sutures  are  removed,  to  allow  the  consolidation  of  the  cicatrices  and 
the  closure,  by  contraction,  of  any  minute  opening  that  may  have 
been  left. 

Although  the  experience  of  Drs.  Sims  and  Emmet  have  proven  the 
propriety  and  efficacy  of  this  kind  of  after-treatment  for  vesico- 
vaginal fistula,  all  of  it  is  not  absolutely  necessary  to  success.  In 
two  instances  operated  on  by  the  author,  the  patients  were  not  con- 
fined to  any  position,  and  were  permitted  to  rise .  from  the  bed  and 
sit  up  part  of  the  time  each  day,  from  the  time  of  the  operation  until 


Fig.  180. 


the  sutures  were  removed.  The  catheter  was  not  worn  in  either  case, 
but  it  was  used  for  the  first  four  days,  every  two  hours,  to  evacuate 
the  bladder.  At  the  end  of  four  days,  the  patients  were  permitted 
and  instructed  to  evacuate  the  bladder  as  often  as  once  in  two  hours 
voluntarily. 

Both  the  patients  were  cured,  and  the  comfort  they  enjoyed  con- 
trasted very  favorably  with  that  of  such  as  were  confined  to  the  posi- 
tion on  the  side  or  back,  and  were  obliged  to  wear  the  catheter  for  ten 
or  fifteen  days.  I  have,  from  time  to  time,  seen  suggestions  in  medical 
journals,  which  I  cannot  now  command,  that  led  me  to  conduct  the 
after-treatment  in  these  two  cases  as  above  stated. 


264 


AFFECTIONS   OF   THE   VAGI^'A. 


Simo7i''s  Method. 

In  Continental  Europe  the  late  Professor  Gustav  Simon,  greatly  dis- 
tinguished himself  in  plastic  operations.  His  operation  for  vesico- 
vaginal fistula  is,  in  many  respects,  different  from  that  above  detailed. 

He  places  his  patient  on  her  back  with  the  breech  very  much  ele- 
vated. In  cases  where  the  fistula  is  near  the  orifice  of  the  vagina,  the 
limbs  are  placed  in  the  position  usual  in  lithotomy.  If  the  fistula  is 
deep,  however,  the  limbs  are  brought  up  and  extended  over  the  sides 

Fig.  181. 


of  the  abdomen  and  breast,  as  shown  in  Fig.  180.  If  the  uterus  is  suf- 
ficiently mobile,  Simon  draws  it  down  to  the  external  organs  of  gen- 
eration, and  thus  places  the  fistula  immediately  under  the  hand  of 
the  operator.  In  order  to  ascertain  the  mobility  of  the  organ,  he 
seizes  the  cervix  with  Museux's  forceps,  and  draws  upon  it  until  the 
vagina  is  inverted,  or  until  it  is  evident  that  the  forcible  traction  re- 
quired will  do  violence  to  some  of  the  tissues.     When  the  cervix  is 


UEINAEY    FISTULA. 


265 


drawn  down  sufficiently,  two  strong  threads  are  passed  through  it  by 
which  it  is  held  in  place. 

Fig.  181  represents  this  stage  of  procedure ;  the  sides  of  the  vulva 
being  held  out  of  the  way  by  levers  made  for  the  purpose. 

When  the  uterus  cannot  be  thus  drawn  down,  Simon  uses  two 
specula,  and  the  levers  in  the  sides  of  the  vulva,  if  necessary.  This 
method  of  exposure  is  very   plainly  illustrated  by  Fig.   182.     One 


large  speculum  draws  back  the  perineum,  and  another,  somewhat 
differently  constructed,  is  placed  under  the  symphysis  pubis. 

The  margin  of  the  fistula  is  prepared  by  cutting  away  all  the  cica- 
tricial tissue,  and  the  paring  is  done  almost  perpendicular  to  the  sur- 
face of  the  vaginal  mucous  membrane.  There  is  some  slight  inclina- 
tion or  declivity  in  the  cut  edges,  but  they  are  very  much  less  bevelled 
than  in  Dr.  Sims's  operation.  Fig.  183  will  give  a  correct  idea  of 
this  part  of  the  operation.     A  comparison  with  Fig.  182  will  give  the 


266 


AFFECTIONS  OF   THE   VAGINA. 


reader  an  idea  of  the  liberality  with  which  Dr.  Simon  considers  it 
necessary  to  pare  away  the  tissue. 

The  wound  is  closed  with  fine  white  silk,  about' the  size  of  a  large 
horsehair.     Each  stitch  is  placed  a  little  more  than  a  line  distant 


Fig  183 


'Vr*^ 


m 


%' 


n      ft       '       \l      ^6- 


^' 


from  the  one  next  to  it.  The  needle  is  carried  entirely  through  the 
lips  of  the  wound,  so  as  to  penetrate  the  vaginal  and  vesical  mucous 
membrane.  In  large  fistula,  every  alternate  stitch  is  placed  further 
from  the  edge  of  the  wound.  Fig.  184  also  shows  this  method  of  in- 
troducing the  stitches.  The  threads  are  carefully  tied  in  a  knot  and 
the  operation  is  completed.  The  closed  fistula  is  well  represented  by 
Fig.  185. 


URIJfAllY   FISTULA. 


267 


Vesico-uterine  fistulse  are  operated  upon  in  the  same  manner. 

Figs.  186  and  187  show  how  such  fistulas  are  pared,  the  stitches  in- 
troduced, and  the  wound  closed. 

In  the  after-treatment,  Dr.  Simon  thinks  it  superfluous,  if  not  in- 
jurious, to  leave  the  catheter  in  the  bladder.  He  directs  us  to  draw 
off  the  urine  once  in  two  or  three  hours,  until  the  patient  can  volun- 
tarily discharge  it,  which  she  can  usually  do  in  the  second  or  third 

Fig  184. 


day.  He  allows  the  patient  to  lie  in  any  position,  and  on  the  eighth 
or  ninth  day  she  can  rise  from  the  bed.  All  straining  at  stool,  before 
the  eighth  or  ninth  day,  should  be  avoided,  if  necessary,  by  the  ad- 
ministration of  opium.  On  the  fourth  or  fifth  day  the  physician 
should  examine  the  wound  with  a  view  to  the  removal  of  the  stitches, 
and  if  they  are  cutting  their  way  through  the  tissues  they  should  be 
cut  and  drawn  out. 


268 


AFFECTIOKS   OF   THE    VAGINA. 


Of  43  fistulas  in  40  women  operated  upon  by  Professor  Simon,  35 
were  perfectly  cure(;l,  2  of  the  women  died,  5  more  of  the  fistulse  were 
nearly  cured,  and  1  was  not  benefited. 

KolpoMeisis. 

Cases  of  urinary  fistula  occur  which  cannot  be  cured  by  an  opera- 
tion like  the  foregoing.  Occasionally  we  meet  with  instances  in  which 
the  damage  is  more  serious,  where  the  septum  between  the  bladder 

Fig.  185. 


and  vagina  is  nearly  or  completely  destroyed,  not  enough  of  this 
structure  being  left  to  enable  us  to  restore  it. 

Surgery  has  successfully  met  these  cases  by  closing  the  vaginal  ori- 
fice or  lower  part  of  the  vaginal  canal,  thus  making  a  common 
receptacle  of  the  posterior  and  lateral  walls  of  the  vagina,  and  the 
remaining  portion  of  the  bladder,  into  Avhich  the  renal  secretions  and 
the  uterine  discharges  are  received  and  from  which  they  find  their  way 


UEINARY   FISTULA. 


269 


out  through  the  urethral  canah  The  vagina  may  be  closed  by  unit- 
ing the  inner  edges  of  the  labia  or  the  anterior  and  posterior  walls 
of  the  vagina  quite  inside  the  orifice.  The  operation  for  uniting  the 
labia  will  be  necessitated  in  some  instances.  We  occasionally  meet 
with  cases  where  the  anterior  wall  of  the  vagina  is  entirely  removed 
from  the  pubis,  and  nothing  is  left  behind  that  bone  to  which  the 
posterior  wall  of  the  vagina  may  be  united.  So  complete  is  this 
removal  of  tissue  that  the  posterior  face  of  the  pubis  is  covered  with 
nothing  but  a  thin  cicatricial  substance.  The  labial  closure  of  the 
vagina  is  the  only  operation  in  this  class  of  extreme  cases. 


Fig.  186. 


The  operation  consists  in  removing  a  ring  of  mucous  membrane  from 
the  inner  margin  of  the  labia,  just  behind  the  orifice  of  the  urethra, 
three-quarters  of  an  inch  deep,  and  then  by  means  of  deep  silver  sutures 
making  perfect  apposition  of  the  denuded  surface.  The  sutures  should 
be  passed  deep  enough  to  include  the  whole  of  the  raw  portion  of  the 
parts,  and  extend  on  the  outside  three-quarters  of  an  inch  in  the  sub- 
stance of  the  labia  bejroiid  their  margin.  The  sutures,  to  insure  union, 
should  be  not  more  than  three  lines  apart.  The  parts  should  be  care- 
fully adjusted  while  the  wires  are  being  twisted,  so  as  to  make  an  even 
adaptation. 


270 


AFFECTIONS    OF    THE   VAGINA. 


When  there  is  sufficient  of  the  vesico-vaginal  septum  behind  the 
pubis  to  permit  its  coaptation  to  the  posterior  wall,  the  operation  per- 
formed, and  proposed  about  the  same  time  by  Simon  and  Bozeman,  is 
preferable  to  the  foregoing.  Simon's  method  is  simple  and  effectual 
in  closing  the  vagina  thoroughly.  He  denominates  the  operation 
Kolpokleisis.  The  vagina  is  held  open  by  the  instruments  and  by  the 
method  described  for  operating  on  fistulse,  and  a  ring  of  mucous  mem- 
brane is  removed  as  represented  in  Fig.  187  and  then  united  by  the 
sutures.     Silver  wire  is  probably  the  best  suture  for  this  operation. 

Fig.  187. 


r- 


Dr.  Simon  operates  as  high  up  in  the  vagina  as  the  disease  will  permit, 
and,  instead  of  confining  the  operation  to  the  urethral  portion  of  the 
cavity,  he  sometimes  operates  so  near  the  os  uteri  as  to  preserve  al- 
most the  entire  length  of  the  anterior  wall  of  the  vagina.  After  either 
operation  the  treatment  will  consist  in  perfect^quietude,  the  use  of 
opium  to  relieve  pain,  and  the  fixed  catheter  to  prevent  an  accumula- 
tion of  urine  until  the  parts  are  healed. 


URINARY    FISTULA. 


271 


Bozeman's  Method. 

Dr.  Bozeman,  whose  operations  have  attracted  attention  in  Europe 
as  well  as  in  this  country,  claims  to  have  made  improvements  upon  the 
operation  for  vesico- vaginal  fistula  as  well  as  in  the  means  and  methods 
of  performing  it.  As  now  employed  his  operation  has  for  its  distinctive 
characters  the  button  suture,  the  position  of  the  patient,  and  a  self- 
retaining  speculum.  The  figure  which  is  here  introduced  will  serve 
to  illustrate  the  position  of  the  patient  and  the  self-retaining  speculum. 
In  paring  the  edges  of  the  fistula  Dr.  Bozeman  makes  the  extent  of 
denuded  surface  rather  greater  than  is  recommended  in  the  foregoing 
pages  and  does  not  place  his  sutures  as  near  together.  After  having  pre- 
pared the  parts  for  coaptation  he  passes  the  two  ends  of  each  suture  re- 
spectively through  the  opening  in  his  adjuster,  as  represented  in  figures 


Fig.  188. 


C  ^     1  B 

Bozeman's  Apparatus  for  Retaining  the  Patient  in  Position. 


taken  from  page  24  of  M.  Andrade  essai  sur  le  traitement  defishdes  vesico- 
vaginalespar  leproc^d^  Americain  modea^  par  M.  Bozeman.  Thus  ad- 
justed the  wound  is  ready  for  the  button,  which  should  be  made  at  the 
time  and  in  accordance  with  the  shape  and  size  of  the  wound.  The 
button  is  cut  out  of  a  thin  sheet  of  lead,  about  one  line  in  thickness, 
long  enough  to  project  about  one-fourth  of  an  inch  beyond  the  sutures 
at  either  end  of  the  wound,  and  a  very  little  more  than  half  an  inch 
wide.  If  the  wound  is  straight  after  it  is  closed  with  the  suture,  the 
button  should  be  the  same ;  but  if  the  wound  is  curved  the  button 
should  be  made  to  suit  the  curvatures.  Then  with  the  "  button-form- 
ing forceps,"  the  groove  along  the  centre  may  be  formed  by  clamping 
across  the  sides  from  one  end  to  the  other.  Thus  formed,  the  button 
is  slightly  concave  on  the  side  that  goes  next  the  closed  wound,  and 


272 


AFFECTIO^IS    OF    THE   VAGIXA. 


has  a  groove  of  almost  a  line  in  depth  along  the  centre,  from  one  end 
to  the  other,  and  is  ready  to  be  perforated  for  the  sutures,  which,  after 
measuring  otf  the  distances  accurately,  is  done  by  an  instrument  for 
the  purpose.  The  operator  should  then  assure  himself  that  all  the 
spiculse  caused  by  the  perforating  process  are  removed,  and  proceed 
to  adjust  the  button. 

Fig.  189  shows  the  sutures  through  the  button  as  it  approximates 
its  future  site  on  the  wound.  The  button  is  pressed  down  evenly 
upon  the  wound  by  means  of  the  blunt  hook,  and  each  suture,  one  after 


Fig.  189. 


Fig.  190. 


the  other,  passed  through  perforated  shot,  and  fixed  by  clamping  the 
shot  with  strong  forceps  for  the  purpose.  Each  suture  should  be  care- 
fully fixed  in  this  way  separately. 

In  adjusting  the  sutures  the  wire  should  be  tightened  by  being 
drawn  through  the  opening  at  the  time  the  shot  is  compressed.  Only 
so  much  traction  should  be  made  as  Avill  bring  the  lips  of  the  wound 
well  up  into  the  groove,  but  not  strangulate  them. 

The  button  thus  applied  is  well  represented  by  Fig.  190.  Dr.  Boze- 
man  claims  for  this  suture  : 

"1.  Separate  and  independent  action  of  the  sutures. 

"2.  Perfect  coaptation  of  the  edges  of  the  fistula,  and  power  (o  hold  them  in  a  cer- 
tain relationship  during  the  reparative  process. 

"3.  Perfect  steadiness  and  support  of  the  edges  of  the  fistula. 

"4.  Protection  of  the  denuded  edges  of  the  fi-itula  from  the  vaginal  and  uterine  dis- 
charges, and  from  tlie  urine,  when  there  happens  to  be  more  than  one  opening,  and  it 
is  not  convenient  or  desirable  to  close  botli  at  the  same  silling." 

We  are  indebted  to  Dr.  Bozeman  for  a  very  ingenious  and  effectual 
method  of  diagnosing  minute  and  otherwise  indistinguishable  fistula?. 
He  calls  it  the  linen  test,  and  describes  it  as  follows  : 


UEINAEY   FISTULA.  273 

"  Pus  and  mucus  in  small  quantities  adhere  to  and  spread  upon  the  surface  of  a  piece 
of  linen  without  being  absorbed  b}'  it,  while  water  or  urine,  on  the  contrary,  even  in 
the  minutest  quantity,  when  brought  into  contact  with  the  same  material,  penetrates 
almost  instantly  the  entire  thickness  of  the  fabric.  The  presence  of  these  fluids,  if  the 
flow  is  continuous,  is  evidenced  by  increasing  saturation  of  the  spot  acted  upon,  and  the 
spreading  of  the  moisture  in  every  direction.  Thus  is  presented  a  most  valuable  and 
reliable  means  of  determining  the  presence  of  urine  in  the  vaginal  or  uterine  canal 
when  the  quantity  is  so  small  as  to  escape  observation  ;  not  only  this,  but  the  precise 
situation  of  its  escape  from  the  bladder  can  be  made  with  the  greatest  certainty  when 
it  would  be  impossible  to  detect  it  by  the  ordinary  means,  owing  to  the  minuteness  of 
the  orifice  or  its  concealment  by  a  fold  of  mucous  membrane. 

"In  using  the  test  nothing  more  is  necessary  than  to  fill  the  bladder  with  water,  and 
then  wipe  thoroughly  dry  the  anterior  wall  of  the  vagina.  A  piece  of  old  linen  is 
now'  rapidly  spread  out  upon  the  latter,  and  pressed  down  smoothly,  the  patient  being 
in  the  angular  position,  upon  the  knees.  In  a  few  moments  the  effect  of  the  fluid 
upon  the  linen  will  be  seen  at  the  place  of  escape  from  the  bladder,  should  the  orifice 
be  even  no  larger  than  a  pin's  point  or  a  fine  bristle.  When  the  patient  is  placed  in 
the  dorsal  position  it  is  seldom  necessary  to  inject  the  bladder  ;  the  natural  flow  of  the 
urine  from  the  kidneys  will  be  found  quite  sufficient  to  mark  the  situation  of  its  un- 
natural escape  into  the  vagina." 

With  regard  to  the  success  of  his  method  of  operation,  as  now  prac- 
ticed by  him,  he  gives  the  following  data : 

"For  the  period  from  1867  to  1870,  17  cases,  having  23  fistula;,  got  24  operations, 
with  the  following  results  : 

"  21  fistulae  completely  closed. 

"1  fistula  completely  closed  in  a  syphilitic  subject  and  afterwards  reproduced. 

"  1  death,  caused  by  intense  heat  of  the  weather  and  consequent  exhaustion  of  the 
patient. 

"  88  per  cent,  of  permanent  cures. 

"  87J  per  cent,  successful  operations. 

"The  syphilitic  case  was  cured  as  regards  the  result  of  the  operation,  and  the  death 
did  not  result  from  causes  connected  with  the  operation.  It  will  be  seen,  therefore, 
that  the  percentage  of  permanent  cures  and  of  successful  operations  is  not  far  below 
the  maximum  limit.  Of  these  23  fistulse  3  were  vesico-uterine,  1  vesico-utero-vaginal, 
1  utero-vaginal,  1  laceration  of  the  urethra,  1  urethro-vaginal  and  recto-vaginal,  the 
latter  admitting  easily  three  fingers  into  the  bowel ;  all  of  which  were  completely 
closed,  with  preservation  of  the  functions  of  all  the  organs  involved." 

In  a  recent  letter  he  says,  with  reference  to  his  oiaerations  : 

"  By  examination  of  my  reported  cases,  treated  by  this  form  of  suture,  you  will  find 
the  inauguration  of  several  new  procedures  in  the  following  affections: 

"1st.  Urethral  lacerations  extending  from  the  meatus  backwards,  a  part  or  the 
whole  length  of  the  canal.  By  a  peculiar  modification  of  my  button,  the  catheter  in 
these  cases  is  supported  and  the  closure  of  the  rent  made  complete  to  the  meatus. 
(See  North  Am.  Med.-Chir.  Review,  July  and  November,  1857.) 

"2d.  Vesico-uterine  fistulae.  A  mode  of  treatment  to  close  the  fistula  and  preserve 
the  functions  of  all  the  organs  intact.  The  operation  consists  in  dividing  posteriorly 
the  anterior  lip  of  the  cervix  uteri  down  to  the  sinus,  then  paring  the  sides  of  the 

18 


274  AFFECTIONS   OF   THE  VAGINA. 

latter  and  closing  the  wound.  (See  Case  V.,  op.  cit.)  This  was  my  first  case,  and 
here  I  got  the  idea  I  have  since  performed  successfully  this  operation  in  three  other 
cases.  In  one  case  the  sinus  opened  so  high  up  in  the  cervical  canal  that  the  utero- 
vesical  fold  of  peritoneum  was  implicated  in  the  operation. 

"The  great  value  of  this  procedure  cannot  be  overestimated.  The  procedure  of 
Jobert,  which  consists  in  paring  the  two  lips  of  the  cervix  and  uniting  them  by  suture, 
is  almost  universally  adopted  by  surgeons  in  this  class  of  cases.  If  the  operation 
proves  successful,  the  menstrual  fluid  is  left  with  no  other  outlet  than  through  the 
small  sinus  (usually  no  larger  than  the  most  delicate  probe)  into  the  bladder,  there 
commingling  with  the  urine  and  finally  escaping  with  it  through  the  urethra.  In  the 
journals  I  have  seen  the  operation  is  claimed  as  a  great  triumph.  The  operation  is 
frequently  performed  by  leading  surgeons. 

"  With  regard  to  this  practice  I  unhesitatingly  condemn  it.  It  is  unsurgical  and 
unjustifiable,  and  should  never  be  performed. 

"  3d.  Vesico-utero-vaginal  fistula.  An  original  procedure  for  its  cure.  (See  Case 
VIII.,  op.  cit.,  1857.) 

"  4th.  Incarceration  of  the  cervix  uteri  in  the  bladder.  An  original  procedure  for 
the  disengagement  of  the  cervix  from  its  confined  position  and  the  closure  of  the 
fistula,  with  preservation  of  all  the  functions.  (See  Case  XV.,  op.  cit.,  and  Cases 
XXVIII.  and  XXXVIII.,  New  Orleans  lied,  and  Surg.  Journ.,  January,  March,  and 
May,  1860.) 

"  I  would  add  here  that  my  cases  are  the  only  ones  to  be  found  upon  record,  and  I 
venture  the  assertion,  without  the  fear  of  contradiction,  that  no  cure  will  ever  be 
effected  by  any  other  form  of  suture  than  the  button.  The  mechanism  of  this  suture 
is  peculiarly  adapted  to  the  successful  treatment  of  this  rare  lesion." 

I  am  not  aware  that  Dr.  Bozeman's  operation  has  been  objected 
to  on  account  of  want  of  success,  for  when  skilfully  performed  all 
acknowledge  its  success.  The  chief  and  perhaps  only  objection  that 
has  had  any  effect  in  preventing  it  from  general  favor  and  practice 
is  complication  and  consequent  difficulty.  This  need  be  no  objection 
if  the  surgeon  is  prej^ared  with  all  the  instruments  now  used  by  Dr. 
Bozeman ;  with  them  the  different  steps  in  the  operation  are  easily 
accomplished.  He  requires  no  assistance  during  the  operation,  a 
consideration  of  no  small  importance. 

Entero-vesical  Fistula. 

Occasional  instances  occur  in  which  from  cancerous  degeneration 
of  the  tissues  of  the  bladder  and  intestinal  canal  lying  in  contact  they 
become  adherent,  and  afterwards  perforated  in  such  manner  as  to 
permit  the  discharge  of  the  excretions  of  one  organ  into  the  other, 
thus  making  an  entero-vesical  fistula,  with  the  urine  passing  into  the 
intestine  and  out  at  the  anus,  and  causing  what  urine  passed  from 
the  urethra  to  be  mixed  with  fseces.  The  author  had  for  several 
months  under  his  care  a  recto-utero- vaginal  fistula.  This  condition 
was  caused  by  perimetritic  inflammation.  The  abscess  perforated  the 
bladder,  uterus,  and  rectum,  and  the  escape  of  faces  as  well  as  urine 
was  observed  from  all  these  cavities.     The  fistulous  openings  were 


ENTERO-VAGINAL    FISTULA — RECTO- VAGINAL    FISTULA.        275 

small  and  must  have  been  tortuous,  as  these  excretions  escaped  in 
very  small  quantities.  The  patient,  a  young  girl,  died  of  tubercular 
consumption  after  having  lived  in  this  miserable  state  eighteen  months. 

Entero-vagina I  Fistula. 

This  is  of  two  kinds,  colono- vaginal  and  recto-vaginal.  The  former 
is  very  rare,  and  is  caused  by  malignant  ulceration  or  grave  perime- 
tritis. The  inflammation,  when  sufficiently  severe  to  cause  commu- 
nication between  the  vagina  and  colon,  usually  extends  up  into  the 
abdomen  and  involves  the  viscera  in  that  cavity  to  a  very  serious 
extent.  The  suppurating  cavity  in  this  case  is  also  large,  and  opens 
in  one  place  into  the  intestinal  canal,  and  at  another  point  of  ulcera- 
tion into  the  vagina,  and  as  the  cavity  of  suppuration  is  slowly  filled 
by  granulations  a  tortuous  canal  is  left,  leading  from  the  bowel  down 
into  the  vaginal  cavity.  If  the  opening  into  the  vagina  can  be  found, 
I  see  no  objection  to  closing  it  with  the  silver  suture.  After  a  long 
time  these  opening  would  probably  close  spontaneously,  as  artificial 
anus  will  sometimes  do. 

Recto-vaginal  Fistula. 

This  accident  does  not  so  frequently  as  vesico-vaginal  fistula  result 
from  puerperal  vaginitis.  Stricture  of  the  rectum,  abscess  of  the 
recto-vaginal  septum  rupturing  into  both  cavities,  and  accidents  with 
instruments,  perhaps,  as  often  cause  it.  It  is  not  so  common  or  fre- 
quent as  vesico-vaginal  fistula,  nor  so  distressing.  The  passage  of  the 
faeces,  if  jDroper  cleanliness  is  observed,  although  disgusting,  is  not  so 
productive  of  inflammation  and  excoriation  as  urine,  and  their  dis- 
charge may  be  controlled  by  appropriate  fixtures.  A  cure  is  also 
more  easily  accomplished;  indeed,  it  is  often  spontaneous.  As  the 
contents  of  the  bowels  pass  intermittingly,  and,  when  in  contact  with, 
the  raw  surface,  do  not  irritate  it  considerably,  the  ulcer  has  time  to. 
contract,  and  healthy  granulations,  in  a  good  state  of  the  general 
health,  result. 

The  symptoms  and  diagnosis  of  this  fistula  are  so  obvious  that  I 
need  not  dwell  upon  them  ;  but  we  sometimes  meet  with  cases  where 
the  opening  is  so  small  and  tortuous,  that  great  patience  in  the  use 
of  the  probe  will  be  required  to  satisfy  ourselves  as  to  its  position  and. 
direction.  The  injection  of  water  into  the  rectum  while  the  parts  are 
under  inspection  will  generally  clear  up  all  doubts. 

Treatment. 

If  we  are  associated  with  these  cases  during  the  ulcerative  condi- 
tion, we  may  conduct  them  to  a  cure  with  some  certainty,  and,  per- 
haps, more  readily  than  after  the  edges  of  the  opening  have  cicatrized. 
The  important  items  of  treatment  at  such  times  are  :  1st,  proper  atten- 


276  AFFECTIONS    OF    THE    VAGINA. 

tion  to  the  bowels ;  2d,  great  cleanliness ;  and  3d,  maintenance  of 
healthy  granulations  until  the  contraction  obliterates  the  opening. 
The  bowels  should  be  kept  quiet  as  much  of  the  time  as  possible. 
To  accomplish  this,  the  diet  should  be  concentrated  and  nourishing 
in  character ;  beef  essence,  milk,  eggs,  crackers,  coffee,  or  tea,  and  if 
necessary  on  account  of  debility,  wine,  or  medicinal  tonics ;  and  if 
the  bowels  have  a  tendency  to  move,  opium  in  such  quantities  as  will 
restrain  them.  Every  four  or  five  days  a  gentle  alterative,  say  three 
grains  of  blue  pill,  followed  by  a  saline  cathartic  ;  after  the  bowels 
have  moved  from  this,  the  opium  may  be  given  to  restrain  them  for 
four  or  five  clays  again,  and  so  on  until  the  opening  is  closed.  During 
this  treatment  there  should  be  frequent  injections  of  water  into  the 
vagina.  The  part  should  be  examined  with  the  speculum  every  day, 
to  see  that  the  edges  remain  raw.  Where  there  is  any  tendency  to 
cicatrize,  the  edges  may  be  freely  touched  with  pure  nitric  acid.  If 
the  cure  is  protracted,  the  acid  should  give  place  to  the  actual  cautery. 
Toward  the  last,  as  the  opening  becomes  small,  especially  if  it  is  tor- 
tuous, a  piece  of  twine,  or  what  is  perhaps  better,  a  silver  or  iron  wire, 
may  be  passed  through  it,  and  the  ends  brought  out  through  the  anus 
and  vagina.  If  the  case  is  chronic  and  the  opening  small,  the  appli- 
cation of  the  acid  may  be  made  every  day  until  the  edges  are  denuded, 
and  then  the  same  course  followed  as  above  directed.  Of  course,  these 
applications  must  be  made  through  the  vagina  with  a  speculum  that 
completely  exposes  the  part  touched.  If  the  place  is  large  and 
chronic,  we  shall  very  much  shorten  the  process  of  cure  by  an  opera- 
tion similar  to  that  for  vesico- vaginal  fistula.  After  having  thoroughly 
evacuated  the  bowels,  the  patient  may  be  placed  in  the  lithotomy 
position,  and  exposing  the  jDarts  to  a  strong  light,  the  perineum  may 
be  retracted  by  the  rectangular  speculum  blade  of  Sims,  while  the 
vulva  is  held  open  by  assistants.  The  edges  are  then  to  be  pared 
thoroughly,  and  the  aperature  closed  with  silver  sutures.  It  is  neces- 
sary to  make  a  larger  raw  surface  on  the  vaginal  than  on  the  rectal 
side,  that  the  rectal  edges  may  lie  together  without  traction.  The 
bowels  will  require  the  use  of  from  two  to  four  grains  of  opium  daily 
to  keep  them  quiet.  They  should  not  be  allowed  to  move  for  ten 
days,  when  a  saline  cathartic  should  be  given,  and  after  it  has  operated 
well,  the  stitches  removed.  During  the  time  between  the  operation 
and  the  removal  of  the  stitches,  the  patient  is  to  remain  quiet  in  bed, 
and  have  injections,  per  vaginam,  of  tepid  water  with  soap,  twice  a 
day.  If  by  this  operation  there  is  imperfect  closure  of  any  part,  the 
treatment  recommended  for  recent  cases  will  suffice  to  complete  the 
cure.  Even  these  larger-sized  fistula  are  sometimes  cured  by  the 
caustic  acids,  the  actual  cautery,  or  tinct.  lytta? ;  but  it  takes  a  longer 
time,  and  is  attended  with  more  jDain  and  annoyance.  The  operation 
on  these  fistulae  will  be  greatly  facilitated  by  having  the  breech  of  the 
patient  projecting  somewhat  over  the  end  of  the  table. 


CHAPTEE    X. 

MENSTEUATION  AND  ITS  DISOKDEES. 

Several  conditions  are  necessary  to  the  healthy  iDcrformance  of  the 
functions  of  menstruation. 

1st.  The  ovaries  must  be  present,  and  sufficiently  healthy  to  pro- 
duce ova. 

2d.  The  uterus  must  be  sufficiently  perfect,  anatomically  and  physi- 
ologically, to  be  the  medium  of  elimination. 

3d.  A  certain,  but  not  as  yet  very  well-defined,  state  of  the  blood 
and  nervous  system  must  exist. 

These  are,  probably,  not  all  the  conditions  necessary  to  perfect 
menstruation ;  but  they  are  the  obvious  and  undoubted  ones. 

The  uterus,  by  virtue  of  the  conditions  upon  which  menstruation 
depends,  is  naturally  a  hemorrhagic  organ ;  and  it  is  in  consequence 
of  its  anatomical  and  physiologicaLpeculiarities  that  the  ordinary  and 
frequently  acting  causes  of  uterine  hemorrhage  are  rendered  so  potent 
and  effective. 

The  more  obvious  phenomena  of  menstruation  are  doubtless  the 
result  of  a  definite  reflex  nervous  influence  exerted  by  the  ovaries 
upon  the  uterus.  Although  this  influence  is  more  distinctly  mani- 
fested in  the  great  hypersemia  which  precedes  the  occurrence  of  the 
catamenial  discharge,  and  the  changes  in  the  utricular  glands  and 
mucous  membrane  of  the  womb,  yet  it  is  unquestionably  constant  in 
its  action  and  parallel  to  that  which  presides  over  the  motions  of  the 
heart,  the  arteries,  and  the  alimentary  canal.  Generated  in  the  nerv- 
ous apparatus  of  the  ovaries,  and  contemporaneous  with  the  changes 
called  ovulation  in  those  organs,  this  influence  is  probably  conveyed 
by  afi"erent  nerves  to  the  genito-spinal  centre  (the  existence  of  which 
was  first  established  by  Budge,  of  Greifswalde),*  or  to  some  other 
reflecting  ganglion,  whence  it  is  sent  back  to  the  uterus,  giving  rise 
to  a  wonderful  series  of  tissue  changes  during  the  month.  Some  of 
these  changes  have  been  lucidly  described  by  Dr.  John  Williams,  in 
the  Obstetrical  Journal  of  Great  Britain  and  Ireland,  and  by  our  own 
talented  young  countryman,  Dr.  Engelman,  in  his  recent  essay  upon 
the  subject,  published  in  the  American  Journcd  of  Obstetrics.  These 
changes  are  aptly  termed  by  Aveling,  nidation  and  denidation. 

A  few  days  before  the  menstrual  flow  makes  its  appearance,  the 

*  Ueber  das  Centrum  genito-spinales  des  N.  sympatheticus.  Virchow's  Arcliiv  f. 
Path.  Anat.  und  Klin.  Med.,  Band  xv.,  S.  115-126. 


278  MENSTRUATION    AXD    ITS    DISOEDEES. 

whole  uterus,  and  especially  its  mucous  membrane,  becomes  greatly 
hypertrophied  and  very  vascular ;  when  the  discharge  begins,  the 
membrane  is  invaded  by  fatty  degeneration.  This  process  is  so  rapid 
that,  in  four  or  five  days,  the  entire  mucous  membrane  disappears, 
leaving  the  muscular  structure  of  the  inside  of  the  uterus  exposed, 
while  some  remnants  of  the  utricular  glands  are  left,  and  found  en- 
tangled among  the  denuded  fibres.  As  soon  as  the  monthly  flow 
ceases,  a  reproduction  of  the  membrane  is  commenced,  and  it  con- 
tinues to  grow  until  at  the  end  of  twenty-eight  days  its  menstrual 
maturity  is  attained.  Accompanying  these  changes  in  the  cavity  of 
the  uterus  are  others  equally  remarkable,  affecting  all  the  other  tissues 
of  the  organ.  The  bloodvessels  become  enlarged,  and  circulate  an 
increased  amount  of  blood ;  the  fibrous  tissue  is  developed  beyond  its 
intermenstrual  condition;  while  hypereesthesia  indicates  extraordi- 
nary nervous  endowment.  In  fact  a  true  hypertrophy  of  the  uterus 
occurs.  During  the  discharge,  the  process  of  involution  reduces  the 
organ  to  its  smallest  dimensions,  and  the  hemorrhage  ceases.  The 
culmination  of  this  hypertrophy  in  the  discharge  of  blood  from  the 
uterus  is  doubtless  not  merely  an  accompaniment,  but  a  consequence 
of  the  breach  of  capillaries  in  the  mucous  membrane.  These  of  course 
are  physiological  phenomena,  but  the}^  strongly  resemble  pathological 
conditions,  and  would  be  so  considered  in  any  other  organ  in  the 
human  economy.  Moreover,  the  dividing  line  between  health  and 
disease  in  uterine  hemorrhage  is  as  difficult  to  trace  as  that  between 
sanity  and  lunacy.* 

Puberty. 

Puberty  is  the  period  at  which  the  development  of  the  human 
female  renders  her  capable  of  childbearing. 

"  An  immense  revolution  takes  place  in  the  organization  of  the  young  girl.  To 
her  thin  slender  form  succeeds  a  round  and  graceful  contour.  Her  step,  uncertain 
and  hesitating,  becomes  firm  and  animated.  The  sweet  and  vivacious  expression  of 
her  eyes  evince  the  ardor  with  which  she  is  endowed.  Changes  no  less  remarkable 
take  place  in  the  system.  The  chest,  narrow  and  compressed,  becomes  expanded  and 
full.  The  lungs  act  more  freely,  the  heart,  more  developed,  throws  the  blood  with 
more  energy  to  the  remotest  parts  of  the  vascular  system.  The  areolar  tissue  is  in- 
creased in  quantity,  fills  up  depressions  and  rounds  out  angles,  making  those  graceful 
curves  in  the  form  that  constitute  female  beauty.  Of  all  the  organs  that  feel  the  in- 
fluence of  puberty  the  uterus  and  its  appendages  are  the  most  affected  by  it.  In  girl- 
hood of  small  volume,  at  this  period,  the  uterus,  the  ovaries,  Fallopian  tubes,  and  the 
breasts  become  greatly  developed.  The  bones  and  muscles  partake  in  the  general 
development.  The  moral  qualities  of  the  girl  are  no  less  the  subjects  of  change.  The 
young  girl,  before  a  mere  child  in  her  tastes,  inclinations,  and  desires,  experiences  a 
complete  metamorphosis.     Restless  and  pensive,  she  does  not  know  whence  come  the 

*  The  Causes  and  Treatment  of  Non-puerperal  Hemorrhage  of  the  Womb,  Interna- 
tional Medical  Congress,  Philadelphia,  September,  1876. 


PUBEETY.  279 

novel  thoughts  that  agitate  her  micd ;  all  her  impressions  are  pleasurable ;  she  is 
penetrated  by  a  glowing  fervor  ;  an  unaccustomed  pruriency  pervades  the  organs  of 
generation.  The  most  important  phenomenon  of  puberty,  its  indispensable  accora" 
paniment,  that  which  transforms  the  young  girl  into  a  woman,  the  first  menstrual 
flow,  manifests  itself." 

This  is  a  translation  of  the  description  given  by  Brierre  de  Boismont 
in  his  Treatise  on  Menstruation.  It  is  a  true  contrast  between  girlhood 
and  womanhood.  This  change  is  not  attained  in  an  instant,  but  is 
the  work  of  years,  and  the  development,  instead  of  always  being 
regular,  steady,  and  equable,  is  in  many  instances  quite  irregular, 
unsteady,  and  unequal.  Imperceptibly  (comparing  short  periods) 
the  lithe,  muscular,  bony,  and  angular  form  of  the  girl  is  lost.  The 
bones  of  the  pelvis,  the  lower  extremities,  and  chest  expand  and  grow, 
but  no  faster  than  during  some  other  periods  of  girlhood  ;  and  the 
uterus,  ovaries,  and  Fallopian  tubes  assume  their  places  and  acquire 
their  size  gradually.  At  ten  years,  perhaps,  down  is  observed  on  the 
pubis,  but  does  not  become  well-grown  hair  until  seventeen  or  eighteen. 
In  from  four  to  eight  years  usually  these  changes  are  complete.  Nor 
does  the  form  assume  the  becoming  loveliness  of  a  mature  maiden 
immediately  at  the  time  the  menses  are  first  produced. 

The  general  and  even  the  genital  development  is  not  complete  for 
years  after  the  first  effusion  of  blood.  A  description  which  portrays 
anything  but  this  gradual  change  is  fanciful  and  misleads  the  student. 
The  sentiments  and  mental  habits  of  the  girl  when  she  first  begins  to 
menstruate  are  still  childish  and  imperfect  compared  with  what  they 
become  after  the  completion  of  her  first  change  of  life.  Nor  do  I  think 
it  any  more  correct  to  say  that  the  changes  in  the  genital  organs  bring 
about  all  the  attributes  that  accompany  their  development;  they  are 
merely  contemporaneous  with  the  other  and  part  of  the  whole. 

The  development  of  the  body  generally,  and  of  the  sexual  system 
to  a  perfect  state,  usually  proceeds  together,  and  ought  to  be  com- 
plete at  the  same  time  and  in  the  same  degree.  But  these  conditions 
do  not  always  obtain.  Occasionally  the  frame  and  all  the  organs  but 
those  belonging  to  the  genital  system  are  developed  into  vigorous 
womanhood,  while  the  latter  do  not  assume  the  size  and  energy  neces- 
sary for  the  establishment  of  the  sexual  functions;  or  what  is  per- 
haps a  more  frequent  condition,  the  individual  is  physically  undevel- 
oped otherwise,  but  possesses  great  sexual  activity  if  not  vigor.  In 
these,  the  general  organization  is  feeble  and  imperfect,  and  incapable 
of  meeting  the  requirements  of  womanhood,  while  the  functions  of 
menstruation  and  childbearing  exist  in  perfection.  The  physiologist 
will  have  no  difficulty  in  predicting,  in  instances  of  this  kind,  the  in- 
fluences that  will  be  exerted  by  the  dominant  sexual  organs.  He  will 
see  in  advance  the  wreck  that  will  be  made  of  the  mind,  heart,  lungs, 
stomach,  nerves,  and  other  organs  by  the  overwhelming  sympathies 


280  MEXSTRUATIOX   AND    ITS    DISOEDERS. 

that  must  arise  from  the  midue  development  of  the  ovaries  and 
uterus. 

When  this  latter  system  is  subordinate  in  development  and  func- 
tion to  the  system  at  large,  then  the  full  health  and  vigor  of  the  indi- 
vidual Avill  not  be  disturbed  by  the  discharge  of  the  sexual  functions. 

The  circumstances  by  which  the  girl  is  surrounded  during  the  time 
when  these  puberal  changes  are  going  on,  have  a  great  influence  ujDon 
the  future  health  of  the  woman.  This  is  the  turning  period  in  the  life 
of  the  woman.  She  is  perfected  or  ruined  in  that  time.  According 
to  her  development  and  surrounding  circumstances  will  be  her  future 
pathological  tendencies. 

The  development  required  for  efl&ciency  and  health,  is  strength  of 
muscle  and  heart,  and  large  capacity  of  stomach  and  lungs.  And  it 
will  require  but  a  few  moments'  reflection  to  remind  the  intelligent 
phj^siologist  that  the  conditions  by  which  girls  at  puberty  are  usually 
surrounded  are  not  the  best  adapted  to  this  development.  The  little 
girl  is  generally  allowed  to  exercise  in  the  open  air  in  the  same  un- 
restrained manner  that  her  brothers  are.  She  exercises  her  muscles 
as  much  as  her  brain,  and  this  exj^ands  her  lungs  and  causes  her  heart 
to  grow  vigorous,  and  her  stomach  to  digest  well.  She  has  no  nervous 
ailments  while  such  freedom  lasts. 

She  is,  however,  not  more  than  ten  or  twelve  years  old  before  she 
is  restrained  in  her  childish  sports.  She  is  instructed  that  it  will, 
become  her  more  to  deport  herself  like  a  little  lady ;  which  means 
that  her  step  must  be  quiet,  her  speech  less  loud  and  energetic.  She 
must  appear  in  the  street  only  when  well  dressed,  and  must  conduct 
herself  as  becomes  a  woman.  She  must  learn  to  sew  and  draw,  which 
means  that  she  sit  still  in  a  stooping  posture ;  or  she  must  go  to  school 
to  sit  and  study  in  a  close  room  with  many  others,  breathing  foul  air 
for  from  four  to  six  hours  a  day,  and  when  she  comes  home  get  her 
lessons  or  "  tasks  "  as  they  are  properly  called.  If  she  has  any  more 
time  she  spends  it  in  practicing  on  the  piano  or  receiving  company 
in  the  parlor.  In  this  round  of  confining  duties  the  lungs  are  not 
expanded  to  their  full  extent  for  many  da3^s  together ;  the  circulation 
is  slow  because  there  is  not  action  enough  to  require  quickness  and 
energy  in  the  distribution  of  the  blood  ;  the  muscles  become  weak 
and  flabby  from  inactivity ;  the  nervous  system  is  taxed  by  study  at 
school  and  at  home,  while  all  the  rest  of  the  body  is  kept  in  great 
restraint.  The  consequences  are  that  debility  and  excitability  are 
predominant  qualities,  and  the  development  of  the  lungs,  heart,  and 
muscles  does  not  keep  pace  with  the  growth  of  the  brain.  If  exercise 
is  required,  dancing  or  calisthenics  is  resorted  to,  because  more  lady- 
like than  playing  ball  or  running  races  in  the  open  air.  The  amuse- 
ments of  this  period  of  life  are  not  less  injudicious.  These  children 
go  to  see  the  minstrels,  go  to  theatres,  ball-rooms,  card  parties,  and 


PUBERTY.  281 

other  places,  where  they  meet  the  opposite  sex  in  such  manner  as  will 
excite  their  emotional  nature,  thus  encouraging  early  sexual  develop- 
ment. About  this  time,  between  twelve  and  sixteen,  the  lungs  are 
confined  by  corsets  that  fit ''  snugly  "  about  the  chest,  preventing  free 
expansion  and  the  easy  play  of  the  diaphragm.  Other  effects  of  tight 
lacing  in  early  as  well  as  later  life,  are  to  press  the  contents  of  the 
abdomen  down  into  the  pelvis,  and  prevent  a  free  return  of  venous 
blood  from  the  lower  part  of  the  body.  This  downward  pressure 
causes  an  accumulation  of  blood  in  the  pelvic  viscera,  the  rectum, 
ovaries,  uterus,  vagina,  etc.,  and  encourages  congestions  and  inflam- 
mations. 

These  influences,  and  a  long  train  of  others  similar  in  their  effects, 
are  kept  up  from  this  time  forward  until  the  girl  is  married,  and  if 
she  is  never  married  always  afterwards.  What  is  usually  termed 
education  is  commenced  too  early,  and  falls  short  of  its  objects  be- 
cause it  is  commenced  too  early.  Mental  culture  is  obtained  too  often 
at  the  sacriflce  of  the  general  health,  and  still  more  frequently  at  an 
expense  of  physical  development  that  forever  mars  the  usefulness  of 
the  woman.  Physical  culture  should  be  more  assiduous  than  mental, 
during  physical  growth.  The  mind  does  not  mature  as  soon  as  the 
body,  and  mental  culture  should  be  behind  physical  growth  instead 
of  before  it.  Six  hours'  study  and  two  hours'  play  should  be  re- 
versed ;  it  should  rather  be  eight  hours  unrestrained  exercise  and  two 
hours'  study.  In  writing  the  above  I  have  very  feebly  portrayed  the 
evils  that  usually  surround  girls  at  the  time  when  the  puberal  changes 
are  going  forward.  Let  any  one  visit  our  schools  for  girls  of  this  age, 
public  or  private,  seminaries  or  boarding-schools,  and  see  the  require- 
ments, restraints,  and  confinements  of  the  day ;  let  him  go  home  with 
them  and  witness  their  want  of  appetite,  languor,  and  restiveness, 
and  then  see  the  training  from  mothers  and  fathers,  who,  in  honesty 
of  affection,  prevent  them  from  going  out  for  fear  of  exposure  or 
improprieties,  and  encourage  them  to  learn  their  lesson  or  music  to 
the  complete  neglect  of  their  bodies,  and  he  will  be  astonished  that 
as  many  survive  the  ordeal  as  now  do.  More  time  is  necessary  for 
physical  development  than  mental,  and  until  this  truth  is  acted  upon 
our  women  will  become  steadily  less  capable  of  bearing  the  hardships 
of  life. 

In  addition  to  the  want  of  balance  in  the  development  of  the 
physical  organization  above  mentioned,  the  circumstances  of  society 
often  cause  premature  and  undue  development  of  the  sexual  organs. 
Girls  of  different  ages  are  congregated  in  large  schools ;  the  younger 
learn  from  the  older  practices  and  imbibe  sentiments  beyond  their 
age,  which  stimulate  their  passions  and  encourage  too  early  and  too 
vigorous  sexual  desires.  The  dress,  the  free  and  easy  association  of 
very  young  people,  taught  to  imitate  their  seniors,  the  literature  easily 


282  AMENOEEHCEA. 

accessible  and  eagerly  sought  after  by  them,  and  many  other  circum- 
stances incident  to  children  raised  in  populous  cities,  are  calculated 
to  bring  out  prematurely  and  cultivate  the  amorous  sentiments  of 
young  people  of  both  sexes.  Opportunity  is  frequently  offered  to 
medical  men  of  large  experience  to  see  lamentable  suffering  in  young 
girls,  the  result  of  some  of  these  causes.  Some  of  the  most  intractable 
cases  of  uterine  disease  I  have  ever  seen  have  occurred  in  girls  under- 
going puberal  develoj^ment,  traceable  to  undue  excitement  of  the 
sexual  organs  while  attending  large  schools  or  seminaries  for  young 
ladies.  During  the  few  years  in  which  the  girl  is  being  developed 
into  the  woman,  she  is  more  suscejDtible  to  morbid  influences  oioerating 
upon  the  uterus  and  ovaries  than  at  any  other  time  in  life,  and  con- 
sequently these  organs  should  be  kept  as  free  as  possible  from  the 
effects  of  all  conditions  which  excite  and  stimulate  them.  During 
this  time  her  education  ought  to  be  one  that  will  keep  her  muscles 
occupied  in  the  discharge  of  useful  duties. 

This  very  brief  summary  of  puberal  pathology  will  do  for  a  starting- 
point  in  the  consideration  of  the  disorders  of  menstruation. 

I  shall  consider  the  disorders  of  menstruation  under  four  different 
divisions : 

1st.  Amenorrhoea. 

2d.  Menorrhagia. 

3d.  Dysmenorrhoea. 

4th.  Misplaced  menstruation  (Metatithmenia). 

Under  these  four  heads  may  be  included  all  the  deviations  met  with 
in  ordinary  practice.  It  is  usual  with  authors  to  make  only  three 
distinct  divisions.  My  fourth  division  is  spoken  of  by  those  who 
have  described  it  as  uterine  heematocele,  hsematoma,  etc. ;  but  I  shall 
give  what  I  consider  good  reasons  for  classing  it  under  the  general 
head  of  menstrual  disorders. 

In  the  march  of  pathological  science  it  will  not  be  surprising  if, 
before  long,  these  terms  are  entirely  dropped  from  the  category  of 
disease,  and  these  derangements  mentioned  as  symptoms  or  errors  of 
function  under  the  circumstances  in  which  they  occur.  All  patholo- 
gists agree  that  they  are  only  symptoms,  and  teach  students  to  look  to 
the  diseases  whence  they  emanate  as  the  proper  objects  of  treatment. 
The  subject  is  not  sufficiently  clear,  however,  to  do  this  now,  and  it  is 
convenient  yet  to  employ  these  terms  as  proper  heads  under  which  to 
group  the  various  phenomena  attending  them. 

AMENOERHCEA. 

Amenorrhoea  means  simply  the  absence  of  menstruation,  and  may 
appear  under  several  different  circumstances. 

1st.  Menstruation  may  never  make  its  appearance. 

2d.  After  having   occurred  it  may  cease,  or,  as  the  term   is,  be 


SYMPTOMS.  283 

"  suppressed ;"  and,  again,  this  suppression  may  be  suddenly  brought 
about  and  attended  with  acute  symptoms,  and  hence  properly  be 
denominated  acute  suppression  ;  or  it  may  not  be  attended  with  acute 
symptoms,  and  may  last  long  enough  to  be  called  chronic. 

3d.  I  think  it  right  to  consider  deficient  menstruation  as  suppres- 
sion, although  but  partial.  This  partial  suppression  assumes  two 
forms,  viz.,  infrequency,  when  the  intervals  are  uncommonly  long ;  and 
scantiness,  the  return  being  regular,  but  the  quantity  of  the  discharge 
much  less  than  it  should  be.  Or  there  may  be  both  scantiness  and 
infrequenc3^ 

4th.  The  menses  may  be  retained  in  the  cavities  of  the  uterus  or 
vagina,  or  both,  after  having  been  effused.  This  retention  is  very 
different  in  many  respects  from  the  suppression,  giving  rise  to  quite 
a  different  set  of  symptoms,  and  requiring  a  separate  sort  of  treat- 
ment, agreeing  with  it  only  in  the  non-appearance  of  the  blood  ex- 
ternally. 

Pathology  and  Morbid  Anatomy. 

The  pathological  states  upon  which  the  symptom  amenorrhoea  is 
based  are  very  numerous,  and  sometimes  inscrutable.  The  more 
obvious  are  the  following  :  Congenital  absence  of  the  uterus  or  ovaries, 
or  both ;  congenital  or  acquired  atrophy  of  these  organs ;  acute  or 
chronic  disease  of  the  uterus  aud  ovaries.  The  general  conditions 
causing  it  are  ansemia,  cachexia,  pregnancy,  and  nursing,  serious  dis- 
eases of  any  of  the  vital  organs  or  nervous  system,  and  occlusion  of 
some  part  of  the  genital  passage. 

Symptoms. 

The  local  symptoms  which  attend  the  absence  of  the  menses  will 
differ  according  to  the  conditions  which  give  rise  to  it.  In  acute 
suppression  we  shall  have  signs  of  great  congestion,  or  inflammation 
of  the  uterus.  The  patient,  after  commencing  to  menstruate,  being 
subjected  to  the  causes  necessary  to  suppression,  such  as  the  partial 
or  general  application  of  cold,  is  seized  with  pain  in  the  back,  hypo- 
gastric region,  and  hips,  attended  with  a  sense  of  chilliness  more  or 
less  intense.  These  symptoms  are  usually  succeeded  by  febrile  reac- 
tion, headache,  pain  in  the  limbs,  general  languor,  white  tongue,  and 
a  persistent  pain  of  varied  severity  in  the  region  of  the  uterus.  There 
is,  in  this  state  of  things,  as  there  seems  to  be,  inflammation  of  the 
uterus  and  ovaries.  The  symptoms  may  subside,  and  generally  do 
in  a  very  few  days,  leaving  more  or  less  local  discomfort  in  the  pelvis 
and  neighborhood.  At  the  next  menstrual  period,  if  the  uterus  is 
not  much  diseased,  and  the  system  not  greatly  deranged,  the  blood  is 
effused,  but  seldom  with  the  same  naturalness  in  quantity,  quality, 
and  painlessness  as  before ;  there  is  often  more  or  less  pain,  which  is 
manifested  henceforth  at  each  successive  period. 


284  AMENOERHCEA. 

At  other  times  the  discharge  fails  to  show  itself  after  having  been 
thus  suppressed,  and  the  case  becomes  chronic,  lasting  an  uncertain 
length  of  time.  When  this  is  the  case,  the  non-appearance  is  likely 
to  be  attended  by  chronic  inflammation  of  the  uterus  and  ovaries,  as 
the  result  of  the  acute  attack,  and  the  morbid  effects  brought  about 
by  uterine  sympathies  derange  the  stomach,  bowels,  liver,  in  fact  all 
the  chylopoetic  organs,  to  such  a  degree  as  to  render  chymification 
or  chylification  imperfect.  Sanguification  will  be  thus  vitiated,  ansemia 
or  cachexia  results,  and  the  patient  becomes  broken  down  and  "  mis- 
erable." We  cannot  but  see  in  this  catenation  of  circumstances  the 
complicated  effects  resulting  from  inflammation  of  the  uterus. 

Should  the  suppression  be  primary, — by  this  I  mean  to  say,  should 
the  menses  never  have  made  their  appearance, — the  girl,  if  old  enough 
and  sufficiently  developed,  will  suffer  differently.  And  there  is  very 
nearly,  if  not  quite,  the  same  set  of  symptoms  present  in  cases  where 
they  have  made  their  appearance  imperfectly  in  quantity  and  quality, 
or  for  a  few  times,  and  then  ceased.  The  patient  suffers  under  the 
symptoms  of  imperfect  sanguification :  inability  to  exercise,  palpita- 
tion of  the  heart,  shortness  of  breath,  torpid  liver  and  bowels,  want 
of  appetite,  or  an  appetite  for  improper  food  at  improper  times,  de- 
spondency, great  apathy,  and  timidity.  The  surface  is  pale,  and 
either  white  and  translucent,  or  more  commonly  of  a  greenish  hue. 
The  sufferings  are  often  very  great  and  protracted,  and  not  unfre- 
quently  merge  into  those  of  tuberculosis,  insanity,  or  other  serious 
organic  diseases.  It  is  not  unusual,  even  in  cases  where  menstruation 
has  never  been  perfectly  established,  to  find  the  patient  afflicted,  also, 
with  symptoms  of  inflammation  of  the  uterus. 

The  general  symptoms  accompanying  scanty  menstruation,  when 
the  scantiness  is  the  result  of  imperfect  establishment,  are  very  much 
of  the  above  character,  viz.,  those  connected  with  ansemia,  etc.  But 
the  scantiness  and  infrequency,  as  also  the  entire  suppression  of  men- 
struation, usually  depend  upon  organic  changes  in  the  uterus  grad 
ually  brought  about  by  chronic  inflammation.  What  these  are  we 
cannot  always  determine.  Sometimes,  however,  we  find  the  fibrous 
structure  condensed  until  the  bulk  of  the  organ  is  smaller  and  harder 
than  natural;  at  other  times  it  is  greatly  enlarged,  as  I  have  verified 
by  examination.  The  most  common  alteration  is  condensation  and 
atrophy.  In  such  instances  there  will,  of  couse,  be  quite  a  different 
set  of  symptoms,  in  fact  many  if  not  all  the  symptoms  found  described 
in  connection  with  chronic  inflammation  of  the  substance  of  the  cervix 
and  body  of  the  uterus.  I  need  not  enumerate  them  here,  but  refer 
the  reader  to  the  article  in  which  the  general  symptoms  of  these  con- 
ditions are  given.  Chronic  amenorrhoea,  or  scanty  or  infrequent  men- 
struation, is  in  this  way  associated  with  the  most  miserable  states  of 
general  health. 


SYiMPTOMS.  285 

We  are  not  to  believe,  however,  that  the  absence  of  the  menses  is 
the  cause  of  such  nervous  suffering  as  we  often  see  associated  with  it, 
but  that  it  is  caused  by  the  condition  of  the  uterus  and  other  organs 
upon  which  the  irregularity  depends.  The  non-appearance  of  the 
menses  on  account  of  the  absence  of  the  uterus  is  not  usually  attended 
with  the  chronic  suffering  I  have  here  alluded  to  ;  ordinarily,  and 
indeed  in  all  the  cases  of  this  kind  to  which  my  attention  has  been 
called,  the  patients  appeared  to  be  perfectly  well.  One  of  these 
patients  was  thirty-three  years  of  age,  another  twenty-seven,  and  a 
third  twenty-two,  and  all  of  them  were  in  perfectly  good  health. 
This  is  an  argument,  I  think,  in  favor  of  the  opinion  just  expressed, 
that  the  serious  and  annoying  symptoms  arise  from  the  pathological 
condition  of  the  uterus,  or  general  conditions  giving  rise  to  it.  The 
only  symptoms  these  patients  complained  of  at  any  time  that  seemed 
to  be  attributable  to  amenorrhoea  were  the  backache,  weight  about  the 
hips,  etc.,  which  denote  the  23resence  of  the  menstrual  molimen.  In 
the  cases  where  amenorrhoea  exists  before  the  organs  are  sufficiently 
developed  to  assume  the  function  of  menstruation,  we  often  observe  a 
good  state  of  health,  even  after  the  person  has  attained  to  an  age  when 
the  menses  are  expected.  I  have  had  occasion  to  see,  examine,  and 
watch  for  several  years  two  cases  of  chronic  amenorrhoea  from  deficient 
development  of  the  uterus,  and  perhaps  of  the  ovaries.  They  were 
both  married.  One  of  them  is  twenty-eight  years  of  age,  has  been 
married  nine  years,  has  never  menstruated,  has  no  sexual  desires,  but 
lives  happily  with  her  husband,  and  desires  to  be  like  other  women 
merely  to  have  a  child  for  him.  There  are  no  distressing  symptoms 
in  her  case.  Her  breasts  and  uterus  are  developed  to  about  the  size 
in  a  girl  of  thirteen  years  of  age.  There  is  hair  upon  the  pubes,  the 
mons  is  well  developed,  as  is  also  the  clitoris.  The  other  has  been 
married  three  years,  is  twenty-five  years  old,  and  resembles  the  first 
completely. 

When  tuberculosis  or  other  serious  diseases  cause  amenorrhoea  they 
are  usually  well  manifested  before  the  suppression  occurs,  but  some- 
times this  symptom  shows  itself  so  early  in  the  case  that  it  is  regarded 
as  the  cause, of  the  disease  instead  of  the  effect. 

From  what  is  said  above,  the  reader  will  see  that  suppression  is  a 
symptom  of  the  absence^  iviperfection,  or  disease  of  some  of  the  organs 
of  generation,  or  is  due  to  some  grave  deterioration  of  the  blood  or 
nervous  energies,  and  that  we  are  to  look  into  all  the  circumstances 
which  attend  upon  it,  with  a  view  to  learn  the  causing  conditions. 
We  shall  not  always  be  fortunate  enough  to  ascertain  this,  and  we 
must  then  content  ourselves  with  conjecture,  and  a  necessary  uncer- 
tainty in  the  treatment  we  adopt. 


286  AMENOERHCEA. 


Amenorrhosa  from  Retention. 

If  the  retention  dates  from  puberty  the  patient  at  the  proper  time 
began  to  experience  the  symjDtoms  of  menstruation.  In  instances 
where  the  retaining  condition  is  acquired,  the  symptoms  will  be  found 
to  have  followed  close  upon  a  severe  inflammatory  or  ulcerated  state 
of  the  uterus  or  vagina.  After  the  retention  is  thus  established  by 
accident,  the  symj)toms  do  not  differ  materially  from  those  manifested 
where  the  occlusion  is  congenital. 

At  first  there  are  very  moderate  pains  in  the  region  of  the  uterus 
at  each  menstrual  period.  From  month  to  month  the  pains  increase 
in  severity  until  they  become  excruciatingly  severe.  The  pains  at 
each  menstrual  epoch  resemble  those  of  labor,  and  cause  the  patient 
quite  as  much  suffering.  They  are  doubtless  caused  by  the  presence 
of  the  blood  in  the  uterine  cavity,  and  have  for  their  object  the  expul- 
sion of  that  fluid. 

Soon  after  the  establishment  of  this  train  of  symptoms  there  ensues 
interparoxysmal  suffering,  much  greater  in  some  instances  than  others. 
There  is  a  sense  of  weight  in  the  pelvis  and  about  the  hips,  weakness 
and  pain  in  the  baclv,  dysuria,  difficulty  in  evacuating  the  bowels  on 
account  of  pressure  upon  the  rectum,  etc. 

There  is,  after  the  first  few  months,  enlargement  of  the  abdomen, 
which  increases  more  slowly  than  in  pregnancy.  The  tumor  is  of  the 
shape  and  in  the  position  of  the  uterus,  and  fluctuates  obversely  upon 
percussion. 

Diagnosis. 

It  is  not  usually  difficult  to  determine  positively  when  there  is 
amenorrhoea,  and  yet  there  may  be  good  reason  to  doubt  in  some 
instances.  It  is  not  necessary  that  there  should  be  an  effusion  of 
blood  to  constitute  menstruation,  for  there  are  periodical  discharges 
from  the  genital  organs  which  indicate  tlie  process  of  ovulation,  and, 
under  certain  conditions  of  the  system,  are  more  appropriate  than  an 
effusion  of  blood.  I  allude  to  a  periodical  discharge  of  mucus  or 
sero-mucus.  The  uterine  congestion  is  not  sufficient  in  quantity  or 
force  to  give  rise  to  hemorrhage,  but  causes  effusion  of  the  thinner 
portions  of  the  blood. 

We  are  often  obliged  to  treat  patients  for  a  time  without  having 
more  than  their  statements  as  a  basis  for  our  diagnosis,  but  fortu- 
nately, in  most  cases,  this  is  sufficient.  We  are  not  justified,  how- 
ever, in  continuing  the  care  of  an  obstinate  case  for  any  length  of 
time  without  making  an  effort  to  verify  or  ascertain  the  fallacy  of 
the  grounds  for  our  opinion.  And,  if  need  be,  we  must  resort  to 
physical  examination.  The  fact  of  our  j^atient  being  a  virgin  should 
cause  deference,  but  not  forbid  an  examination  indispensable  to  a 


DIAGNOSIS.  287 

correct  understanding  of  the  cause  of  a  condition  that  is  destroying 
her  life.  I  need  only  mention  that  suppression,  attended  with  acute 
inflammation  of  the  uterus  and  ovaries,  will  be  attended  with  marked 
and  almost  invariably  unmistakable  symptoms.  The  pain,  fever, 
tenderness,  and  sympathetic  symptoms  will  leave  no  room  for  doubt. 
Anaemia,  cachexia,  nursing,  etc.,  are  obvious  conditions,  and  will  be 
easil}'-  made  out  by  very  little  attention. 

Correctness  in  diagnosis  may  be  attained  with  great  certainty  when 
there  is  physical  defect  in  the  genital  organs,  by  proper  direct  exami- 
nations of  them,  and  they  should  be  instituted  when  other  means  fail 
to  satisfy  us.  The  presence  or  absence  of  the  uterus,  in  most  instances, 
can  be  satisfactorily  determined  by  introducing  the  finger  into  the  rec- 
tum and  a  catheter  into  the  bladder,  and  approximating  them.  If  it  is 
present,  its  thickness  interposed  between  the  two  will  prevent  the  finger 
from  defining  the  shape  of  the  instrument;  if  it  is  absent,  they  maybe 
made  to  touch  with  the  intervention  of  the  walls  of  the  rectum  and 
bladder.  The  catheter,  in  this  examination,  should  be  introduced 
deep  into  the  bladder,  and  the  finger  as  far  up  the  rectum  as  possible. 
With  this  precaution,  there  can  hardly  be  a  mistake.  I  have  met  with 
several  instances  of  congenital  absence  of  the  uterus,  and  in  all  the 
vaginae  were  absent,  but  each  case  presented  all  the  external  evidence 
of  womanhood.  The  mons  veneris  was  perfect  and  covered  with  hair, 
and  the  clitoris,  labia  majora,  and  breasts  were  well  developed.  The 
patients  had  the  demeanor  of  women,  and  assured  me  that  their  desire 
for  the  society  of  men  was  as  great  as  usual,  and  that  they  experienced 
strong  sexual  feeling.  One  of  them  had  married,  and  was  defending 
herself  in  a  suit  for  divorce,  upon  the  ground  of  her  entire  ignorance 
of  any  anatomical  defect  in  organization  ;  another  was  about  twenty- 
two  years  of  age,  and  submitted  to  an  examination  with  the  hope  of 
having  a  correction  of  the  physical  defect,  preparatory  to  entering 
matrimony.  It  is  possible  that  the  vagina  may  be  absent  while  the 
uterus  is  perfect  in  formation — the  same  examination  will  furnish  us 
with  proof — or  the  vagina  may  be  occluded  from  defect  of  formation. 
This  can  be  determined  in  the  manner  I  shall  presently  describe.  Ab- 
sence of  the  ovaries  cannot  always  be  determined  by  physical  examin- 
ation, but  there  is  generally  such  a  complete  absence  of  the  signs  of 
womanhood  in  these  cases  that  we  cannot  long  hesitate.  The  mammae 
are  not  prominent,  the  manners  peculiar  to  the  sex,  desire  for  the  society 
of  males,  and  sexual  j^ropensity,  are  absent.  There  is  no  hair  on  the 
pudenda,  and  the  whole  external  organs  are  not  developed.  The  signs 
are  the  same  at  any  age.  The  patient  at  mature  age  presents  no  more 
evidence  of  sexuality  than  the  little  girl. 

I  have  very  recently  met  with  an  instance  of  congenital  atrophy  of  the 
uterus.  The  patient,  although  now  twenty-eight  years  of  age,  has  not 
menstruated,  unless,  as  she  doubtfully  said,,  twice  very  scantily  when 


288  AMENOEEHCEA. 

about  seventeen  years  of  age.  She  is  rather  above  medium  size,  and 
possesses  all  the  characteristic  appearances  of  womanhood.  She  has 
enjoyed  fair  health  until  the  last  twelve  months.  For  the  past  year 
she  has  suffered  from  distressing  palpitation  of  the  heart,  which  almost 
incapacitates  her  for  business.  She-  has  been  married  nine  years, 
during  which  time  she  has  enjoyed  sexual  intercourse  indifferently. 
She  has  no  monthly  pains,  no  signs  of  menstrual  congestion,  and 
nothing  by  which  to  know  when  to  expect  that  function.  Her  mammee 
are  about  the  size  in  a  girl  of  thirteen  or  fourteen  years,  the  diameter 
being  about  two  inches  and  a  half,  with  a  thickness  at  the  nipple  of 
about  three-quarters  of  an  inch.  The  nipples  are  very  small.  The 
labia  and  mons  veneris  are  undeveloped,  and  the  vaginal  orifice  is 
narrow.  The  uterus  could  be  felt  in  its  usual  position  or  rather  higher 
up  in  the  pelvis,  but  was  very  light  and  small.  When  the  fingers  were 
placed  under  it  in  the  vagina,  and  it  was  pressed  down  from  above,  it 
gave  the  sensation  of  diminutiveness,  apparently  not  exceeding  half  its 
natural  size.  The  ordinary  uterine  sound  would  not  enter  it  more  than 
half  an  inch.  A  probe  with  an  extremity  about  a  twelfth  of  an  inch  in 
diameter,  freely  passed  up  one  inch  and  a  half.  From  all  this,  it  was 
plain  that  the  uterus  was  in  a  state  of  atrophy  ;  and  I  infer  that  the 
ovaries  were  so,  from  the  absence  of  the  nervous  signs  of  menstruation. 

The  size  of  the  organs,  as  measured  by  the  plan  above  indicated, 
determines,  together  with  the  history  of  the  case,  that  it  is  congenital 
atrophy.  Acquired  atrophy  is  confined  generally  to  the  uterus,  while 
congenital  atrophy  generally  involves  all  the  genital  organs,  including 
the  breasts  and-  nipples. 

I  have  met  with  a  number  of  instances  of  acquired  atrophy,  which 
by  carefully  tracing  their  history,  I  could  attribute  to  early  miscarriage 
which  it  seemed  to  folloAV.  And  this  atrophied  condition,  doubtless,  was 
hyperinvolution  of  the  organ  after  abortion.  In  looking  over  the  men- 
strual history  of  these  sufferers,  there  was  a  time  when  they  menstru- 
ated normally,  and  the  function  was  disturbed  after  having  been  thus 
established. 

When  amenorrhcea  is  attended  by  chronic  inflammation  of  the  uterus, 
a  not  unfrequent  occurrence,  the  speculum  and  probe  will  reveal  the 
condition  beyond  the  i3robability  of  making  a  mistake.  I  have  seen 
the  worst  forms  of  indigestion,  and  very  great  emaciation,  attend  this 
condition ;  in  fact,  I  have  seen  no  other  benign  disease  of  the  uterus 
produce  so  much  emaciation  as  this.  The  patient  is  sometimes  bed- 
ridden for  months.  In  two  instances  recently  cured  by  local  treat- 
ment and  proper  dietetics  and  hygienic  regulations,  the  patients  had 
been  reduced  to  two-thirds  of  their  ordinary  weight. 

Diagnosis  of  Retention. 

Upon  examining  the  genital  canal  it  will  be  found  occluded  at  some 
point  between  the  external  labia  and  the  internal  os  uteri.     If  the  hy- 


PROGNOSIS.  289 

men  is  imperforate  the  vagina  cannot  be  penetrated.  If  the  occlusion 
is  higher  up,  it  may  be  found  by  the  finger  and  probe.  By  intro- 
ducing the  finger  into  the  rectum  and  a  catheter  into  the  urethra,  the 
bladder  and  rectum  will  be  found  widely  separated,  the  catheter  pass- 
ing up  close  behind  the  pubis,  and  the  finger  being  pressed  strongly 
against  the  sacrum.  The  finger  in  the  rectum  will  easily  determine 
how  near  the  external  organs  the  obstruction  is. 

The  history,  the  non-appearance  of  the  menstrual  fluid,  the  slow 
enlargement  of  the  abdomen,  periodic  painful  paroxysms,  and  the  oc- 
clusion of  some  part  of  the  vagina  or  uterine  cervix,  are  quite  enough 
to  distinguish  it  in  most  cases. 

Auscultation  and  palpation  will  establish  the  diagnosis  between  re- 
tention and  pregnancy. 

Prognosis. 

The  curability  of  amenorrhoea  will  dejDend  on  the  causing  condi- 
tions. When  occlusion  of  some  portion  of  the  genital  canal  prevents 
the  discharge  of  the  menses,  we  can  usually,  by  surgical  means,  evacu- 
ate it,  and  establish  an  outlet  for  the  future.  Although  simple  and 
easy  of  accomplishment,  the  evacuation  of  a  long-retained  and  consid- 
erable accumulation  is  always  attended  with  hazard.  In  the  first 
place,  inflammation  may  foil  our  efforts  to  establish  a  permanent  via- 
duct for  the  blood  which  may  be  discharged  from  the  uterine  vessels ; 
and  in  the  second,  this  process  may  be  so  great  and  extend  to  the 
-peritoneum  in  sufficient  intensity  as  to  cause  the  death  of  the  patient. 
Amenorrhoea  from  anaemia  may  be  pretty  surely  cured ;  it  is  the  cur- 
able variety  compared  with  those  occurring  from  other  causes.  When 
arising  from  inflammation,  it  will  also  generally  yield  to  apj)ropriate 
treatment,  as  the  cure  wholly  depends  upon  the  removal  of  the  caus- 
ing conditions.  The  cachexia  which  may  produce  amenorrhoea  are 
often  entirely  incurable,  and,  therefore,  our  prognosis  must  be  unfavor- 
able when  they  are  associated. 

In  cases  of  absence  of  the  ovaries  or  uterus,  we  cannot  expect  to  do 
good  by  treatment.  Where  there  is  only  atrophy  of  the  organs,  we 
may  hope  that  some  of  the  ingenious  contrivances  to  increase  their 
development  which  our  profession  of  the  present  day  affords  (they 
have  almost  all  emanated  from,  or  been  perfected  by,  the  fertile  genius 
of  Professor  Simpson,  of  Edinburgh),  may  enable  us  to  succeed.  It 
cannot  be  concealed,  however,  that  these  causing  conditions  will  often 
resist  every  means  within  our  reach.  To  sum  up,  then,  according  to 
my  observation,  when  suppression  arises  from  any  other  causing  con- 
dition than  general  anaemia,  or  inflammation  of  the  uterus  or  ovaries, 
the  prognosis  is  not  very  promising,  and  we  should  be  cautious  in 
promising  a  speedy  and  permanent  cure.  Failure  in  the  function  of 
menstruation  is  pretty  sure  to  be  accompanied  with  an  inability  for 

19 


290  AMENOEEHCEA. 

conception  ;  imperfection  of  it  is,  likewise,  very  frequently  an  evidence 
of  barrenness.  This  is  particularly  the  case  with  scantiness.  When 
menstruation  is  infrequent,  but  the  function  is  otherwise  perfect,  the 
patient  is  often  prolific.  I  have  known  a  woman  for  several  y^ars, 
who  does  not  menstruate  more  than  three  times  in  a  year,  and  then 
not  at  regular  intervals,  and  yet  in  the  last  six  years  she  has  had  two 
children,  conception  following  immediately  after  one  of  these  irregular 
menstrual  discharges. 

Treatment. 

We  should  always  bear  in  mind  the  fact  that  amenorrhoea  is  but  a 
symptom,  and  endeavor  to  amend  the  condition  or  disease  upon  which 
it  depends.  This  rational  mode  of  procedure,  however,  is  not  always 
practicable,  for  unfortunately,  as  has  been  more  than  once  stated,  we 
cannot  in  every  instance  ascertain  precisely  the  condition.  In  such 
cases  we  make  use  of  remedies,  or  plans  of  treatment,  which,  from  the 
success  that  has  occasionally  followed  their  use,  have  gained  the  title  of 
emmenagogues.  This  term  signifies  promoter  of  menstruation.  Are 
there  any  direct  emmenagogues  ?  I  think,  in  the  nature  of  things, 
there  cannot  be.  To  cause  a  flow  of  the  menses  proper,  which  depends 
upon  ovulation  for  its  existence,  they  must  produce  or  promote  the 
evolution  of  ova.  That  there  are  remedies  and  plans  of  treatment 
which  indirectly  promote  the  menstrual  discharge  I  think  there  is 
very  little  doubt.  In  a  general  way  we  ought  to  consider  this  class  of 
remedies  as  producing  their  effects  in  two  different  modes,  one  by 
causing  the  growth  and  production  of  ova,  and  the  other  the  discharge 
of  blood  as  a  hemorrhage.  It  would  be  better,  then,  to  say  that  they 
are  oviferous  in  their  nature  in  the  first  case  and  hemorrhagic  in  the 
second.  To  the  first  order  belong  the  preparations  of  iron  and  other 
mineral  and  vegetable  tonics,  nutritious  diet,  exercise  in  the  open  air? 
diversion  of  mind,  travel,  sea-bathing,  and  in  fact,  everything  which, 
by  correcting  derangement  of  the  vital  organs  and  generating  good 
blood  and  plenty  of  it,  is  promotive  of  healthy  functional  action  gen- 
erally. To  the  second  belong  aloes,  savin,  cantharides,  and  any  hy- 
gienic measures  which  determine  blood  to  the  pelvic  organs,  as  foot-, 
hip-,  and  leg-baths,  sinapisms  to  the  feet  or  legs,  etc.  In  many  instances 
they  may  very  properly  be  combined. 

When  amenorrhoea  results  from  cold  applied  to  the  surface  or  lower 
extremities,  or  from  any  cause  suddenly  acting  to  suppress  the  flow, 
the  uterus  and  ovaries  are  bordering  on,  if  not  in,  a  state  of  acute 
inflammation,  and  the  remedies  for  it  should  be  directed  to  the  relief 
of  the  diseased  organ  or  organs.  The  question  very  naturally  arises, 
can  we,  or  ought  we  do  anything  to  cause  the  return  of  the  flow  im- 
mediately upon  its  suppression,  and  if  so,  what?  Experience  teaches 
us  that  if  the  flow  can  be  reproduced  in  a  very  few  hours  after  its  sup- 


TREATMENT.  291 

pression,  before  general  reaction  occurs,  the  turgid  and  phlogosed  con- 
dition of  the  sexual  apparatus  may  subside  into  a  condition  of  health, 
and  that  this  can  sometimes  be  done  by  judiciously  managed  stimula- 
tion ;  but  if  the  flow  is  not  re-established  in  a  few  hours,  we  need  not 
expect  it  to  recur  until  the  next  period,  if  then,  and  it  is  injudicious  to 
continue  stimulation  beyond  a  very  short  period.  Then  what  is  the 
proper  course  of  stimulation?  If  our  attention  is  called  to  the  case 
within  a  few  hours,  and  there  is  not  much  febrile  reaction,  we  may 
very  properly  direct  a  hot  bath  to  the  whole  person  of  the  patient 
below  the  waist  for  half  an  hour.  The  patient  should  then  be  put  in 
bed,  and  large  sinapisms  placed  upon  the  inner  portion  of  the  thighs 
and  hypogastrium,  and  allowed  to  remain  until  a  strong  rubefacient 
effect  is  produced,  when  they  may  be  removed,  and  the  whole  replaced 
by  a  hot  linseed-meal  poultice.  While  these  measures  are  being  ac- 
complished, we  should  administer  copious  draughts  of  some  kind  of 
warm  tea.  I  cannot  approve  of  the  gin-slings  or  toddies  given  so  freely 
under  these  circumstances ;  they  often  do  harm  by  their  excessive 
stimulation,  rendering  the  inflammation  a  fixed  evil. 

Should  the  flux  not  return  in  twenty-four  hours  from  the  time  of 
suppression,  it  would  be  unreasonable  to  expect  and  injudicious  to 
continue  treatment  to  cause  it  to  do  so.  It  then  remains  for  us,  if 
possible,  to  remove  the  phlogosed  condition  of  the  organs,  so  that  they 
may  be  in  a  state  to  resume  their  functions  at  the  return  of  the  next 
ensuing  menstrual  period. 

-  It  will  be  found,  I  think,  that  for  the  first  month,  in  case  of  an  acute 
suppression,  especially  in  plethoric  patients,  the  most  successful  course 
of  treatment  will  consist  in  moderate  antiphlogistic  and  alterative 
means,  kept  up  steadily.  The  one  I  have  ordinarily  followed  consists 
of  counter-irritants  to  the  hypogastric  region ;  the  hip-bath  of  tepid 
water  twice  a  day  ;  six  to  ten  grains  of  blue  mass  every  third  night,  to 
be  followed  in  the  morning  by  a  seidlitz  powder;  and  abstinence  from 
all  stimulants  and  highly  seasoned  food.  If,  however,  the  suppression 
continue  beyond  the  second  period  after  the  suppression,  it  may  be 
attended  with  chronic  inflammation,  with  or  without  general  anaemia 
etc.,  and  will  come  under  some  of  the  conditions  hereafter  to  be 
considered. 

Amenorrhoea  connected  with  chronic  inflammation  of  the  uterus  or 
ovaries  may  be  treated  as  I  have  elsewhere  directed  those  affections  to 
be  managed.  I  think  that  it  is  not  very  common  for  suppression,  in 
the  chronic  form,  to  depend  upon  inflammation  alone.  More  frequently 
the  causes  of  amenorrhoea  exist  in  the  condition  of  these  organs  that 
remains  after  inflammation,  such  as  condensation  of  fibrous  tissue, 
either  with  or  without  atrophy.  The  same  treatment,  with  little  vari- 
ation, is  applicable  to  both.  I  shall  have  occasion  to  detail  the  treat- 
ment in  speaking  of  atrojjhy  and  want  of  development. 


292  AMENORRHCEA. 

Another  condition  which  succeeds  inflammation  of  the  uterus  and 
ovaries,  after  an  acute  suppression,  is  ana?mia.  For  there  certainly  are 
cases  in  which  an  impoverished  state  of  the  blood  succeeds  an  acute 
suppression,  and  in  turn  prevents  the  re-establishment  of  the  flow.  A 
tonic,  roborant  treatment,  applicable  to  ansemia  arising  from  other 
causes,  may  be  instituted,  if  need  be,  even  before  the  inflammatory 
condition  of  these  organs  has  entirely  subsided.  Perhaps  a  little  more 
attention  to  alteratives,  in  connection  with  the  tonics,  is  necessary  in 
this  class  of  cases.  When  an£emia  is  the  primary  condition  upon 
which  amenorrhoea  depends,  it  will  almost  always  be  found  depen- 
dent upon  some  preceding  affection.  Indigestion,  connected  with  a 
slow  or  depraved  state  of  the  secretions  of  the  alimentary  canal,  often, 
by  preventing  the  introduction  of  nutritious  elements  into  the  blood, 
induces  ansemia.  This  condition  arises,  for  the  most  part,  in  one  of 
two  ways, — either  the  nervous  energy  necessary  to  the  sustenance  of 
the  functions  is  diverted  toother  objects,  as  mental  training  in  the 
school-girl,  or  the  circulation  in  the  abdominal  organs  is  too  sluggish 
on  account  of  sedentary  habits,  as  with  the  sewing-girl.  Sometimes 
want  of  exercise  and  too  great  a  tax  upon  the  brain  from  studies, 
anxiety,  etc.,  co-operate  in  the  same  individual.  Ansemia  may  be 
produced  by  a  great  variety  of  causes  besides  those  above  mentioned, 
but,  according  to  my  experience,  these  are  far  the  most  frequent.  I 
would  not  have  the  reader  believe,  because  I  have  given  the  school- 
girl and  the  sewing-girl  as  instances  of  amenorrhoea,  that  they  are  the 
only  persons  in  whom  the  same  character  of  causes  operate  in  the 
same  way.  Very  many  fashionable  young  ladies,  who  might  enjoy 
the  blessings  of  relaxed,  diverted,  or  healthily  employed  minds,  and 
appropriate  and  enlivening  exercise,  become  anaemic  from  sheer  lazi- 
ness and  the  nervous  anxiety  connected  with  envy. 

Bearing  in  mind,  then,  the  causes  of  indigestion  and  ansemia,  we 
must,  first  of  all,  thoroughly  revolutionize  the  habits  and  circumstances 
of  the  patient,  making  plenty  of  outdoor  exercise  one  of  the  main 
conditions.  Riding  in  a  carriage  is  not  outdoor  exercise  for  these  pa- 
tients ;  they  must  ride  on  horseback,  or,  what  is  very  well,  walk,  run 
and  romp.  An  excellent  sort  of  diversion  for  the  mind  is  occupation 
in  domestic  duties,  making  beds,  sweeping,  cooking,  washing,  caring 
for  and  attending  children,  etc.  The  mind  and  body  are  both  em- 
ployed in  a  varied  and  diverse  manner  in  these  household  duties,  and 
it  will  be  found  that  exercise  both  of  body  and  mind  is  most  profit- 
able as  it  is  most  diverse  and  varied.  While  it  is  true  that  some  kinds 
of  exercise,  as  walking  or  riding,  may  be  made  to  call  into  play  a  great 
many  muscles,  yet  the  whole  routine  of  duties  presenting  themselves 
in  the  business  of  housekeeping,  by  personally  doing  the  work,  is  more 
beneficial  than  all  others  devised.  This  lesson  is  taught  by  the  con- 
trast between  the  young  mistress  and  her  servant. 


TEEATMEJST.  293 

In  addition  to  the  adoption  of  a  more  rational  course  of  habits  for 
the  patient,  much  may  be  done  by  the  judicious  use  of  medicines. 
Almost  invariably  the  tonics  must  be  preceded  by,  or  accompanied 
Avith,  alteratives  and  laxatives.  The  stomach  will  no  more  recognize 
and  respond  properly  to  a  tonic  that  is  introduced  into  it  until  pre- 
pared by  correcting  the  secretions,  quickening  the  gastric  circulation, 
and  unloading  the  bowels,  than  it  will  digest  food  under  similar  cir- 
cumstances. The  alteratives  suitable,  generally,  are  mercury  in  some 
form,  taraxacum,  and  turpentine.  When  the  bowels  are  torpid,  the 
stools  dry  and  of  unnatural  color,  particularly  if  the  color  is  light, 
from  three  to  six  grains  of  blue  mass  given  every  third  night,  and  fol- 
lowed next  morning  by  a  seidlitz  powder,  or  sufficient  sulphate  of 
magnesia  to  cause  one  or  two  evacuations,  is  an  admirable  alterative. 
Ten  grains  of  good  extract  of  taraxacum,  with  a  minute  quantity,  say 
the  twentieth  of  a  grain,  of  bichloride  or  biniodide  of  mercury,  three 
times  a  day  for  two  or  three  days,  generally  does  very  well.  The 
mercury  should  not  be  given  with  the  taraxacum  longer  than  three 
days,  and  then  intermitted  for  a  week,  but  the  taraxacum  may  be  given 
steadily  for  weeks.  An  excellent  alterative  for  the  stomach  is  Venice 
turpentine.  Ten  grains  three  times  a  day  after  eating,  on  sugar,  alter- 
nated or  given  with  some  of  the  mercurial  preparations,  proves  often 
of  great  service.  I  cannot  but  mention  the  compound  confection  of 
black  pepper,  made  in  imitation  of  Ward's  paste,  as  having  frequently 
an  excellent  laxative  and  corrective  effect  on  a  weak  state  of  the  stom- 
ach accompanied  with  constipation.  I  have  known  it  to  cure  some  of 
the  most  obstinate  cases  of  constipation  attended  with  anaemia. 

If  there  is  not  scantiness  of  secretions,  but  slowness  of  peristaltic 
movement,  we  ought  to  depend  on  rhubarb  and  aloes.  The  compound 
aloetic  pill  is  a  good  preparation.  In  the  selection  of  tonics  we  should 
bear  in  mind  the  difference  between  the  stomachic  and  blood  tonics. 
Iron  is,  perhaps,  the  only  direct  blood  tonic,  while  there  are  a  great 
many  articles  that  act  as  stomachics.  Almost  all  the  bitter  vegetables 
ranged  under  that  head  in  the  books  are  useful  under  certain  circum- 
stances. The  stomach  tonics,  by  improving  digestion,  are  indirectly 
blood  tonics,  so  that  they  are  sometimes  all  that  are  necessary.  In 
many  instances,  too,  the  stomach  must  be  prompted  by  the  bitters,  or 
other  stomachics,  before  it  will  absorb  or  assimilate  iron.  The  bitter 
may  precede  the  iron,  or  be  administered  simultaneously  with  it.  It 
is  sometimes  convenient  and  profitable  to  combine  the  alterative  and 
stomach  tonic.  A  mixture  of  this  kind,  often  used,  is  the  compound 
tincture  of  cinchona,  with  bichloride  of  mercury  dissolved  in  it. 
The  tincture  of  gentian,  or  colomba,  answers  very  well  compounded 
with  mercury.  Extract  of  gentian  and  Quevenne's  iron  compounded 
in  a  pill  produce  good  results  on  the  ansemic  patient.  If  we  under- 
stand the  principle  that  governs  the  treatment  in  such  cases,  we  may 


294  AMENORRHCEA. 

readily  find  the  means  to  accom23lisli  our  ends,  by  alteratives,  stom- 
ach tonics,  and  blood  tonics. 

The  each exiee,  several  of  which  interfere  with  the  regularity  of  the 
function  of  menstruation,  must  be  treated  as  if  the  menses  were  present 
in  their  normal  quantity,  and  in  these  cases  the  amenorrhoeal  compli- 
cation is  of  no  importance,  hence  special  efforts  to  restore  the  flow  are 
injudicious,  and  in  most  cases  injurious. 

In  cases  of  defective  nervous  energy  we  may  expect  benefit  from  the 
direct  application  of  electricity  to  the  uterus,  or  to  the  nerves  that 
supply  it.  In  a  paper  read  before  the  New  York  State  Medical  Society, 
by  A.  D.  Rockwell,  M.  D.,*  I  find  the  following  statement : 

"Amenorrhcea  is  a  symptom  that  yields,  perliaps,  more  readily  to  some  one  of  the 
many  formf^  of  electrization  than  to  any  or  all  other  methods  of  treatment.  In  cases 
dependent  on,  or  associated  with,  general  debility,  general  electrization  is  of  course 
indicated  ;  but  where  all  external  efibrts  have  been  fruitless,  internal  electrization  is  not 
infrequently  followed  by  an  immediate  and  satisfactory  flow." 

He  gives  a  case  as  illustrative  of  the  efficacy  of  his  method  of  per- 
forming local  electrization : 

"I  introduced  a  cup-shaped  metallic  electrode  to  the  uterus,  so  that  the  os  was  com 
pletely  surrounded,  and  appilied  the  positive  pole  firmly  against  the  abdomen  im- 
mediately above  the  pubes.  The  current,  which  was  of  considerable  strength,  I  reversed 
rapidly  a  number  of  times  during  the  seance,  and  on  the  following  day  repeated  the 
application.  In  less  than  six  hours  after  making  the  second  attempt,  slight  signs  of 
returning  menstruation  were  manifest,  and  steadily  increased  until,  as  regards  quantity, 
the  flow  was  quite  natural.  The  patient  was  immediately  relieved  of  all  her  distressing 
spasmodic  symptoms,  and  at  the  present  time  (three  weeks  having  elapsed  since  the 
treatment)  still  remains  free  from  them." 

Quer}'.  Was  this  menstruation  or  metrorrhagia  ? 
Dr.  Parvin,  in  the  same  journal,  says  : 

"  The  positive  electrode  passed  into  the  uterine  cavity,  the  negative  applied  to  tlie 
hypogaslrium,  gives  oftentimes  a  very  prompt  success  in  inducing  a  sanguineous  dis- 
charge from  the  uterus;  but  in  order  that  such  result  should  follow,  this  means  should 
be  used  only  at  a  time  when  the  other  phenomena  of  menstruation  manifest  themselves, 
the  flow  only  wanting." 

The  faradic  is  the  form  of  electrization  recommended  by  both  these 
gentlemen. 

In  patients  well  developed  in  most  respects,  whose  genital  system 
is  deficient,  the  menses  cannot  be  produced  unless  these  organs  grow 
and  become  more  active.  Anything  that  will  stimulate  these  organs 
will  occasionall}'  bring  this  result  about.  Wedlock  is  a  remedy  some- 
times. The  indulgence  in  society,  and  the  recreations  of  it,  in  com- 
pany with  men,  sometimes,  through  the  moral  faculties,  stimulate  the 

*  American  Practitioner,  Mav,  1872. 


TREATMENT.  295 

genital  organs  towards  development.  The  stimulus  thus  afforded  by 
society  is  one  of  the  beneficial  effects  resulting  from  the  change  of 
habits  in  young  girls  who  go  to  boarding-schools  until  sexually  dwarfed 
by  confinement  to  the  uninteresting  society  of  their  own  sex. 

Sir  James  Y.  Simpson  has  recommended  an  instrument,  which  he 
calls  an  "  intrauterine  pessary,"  to  bring  about  this  development.  It  is 
equally  applicable  to  cases  of  atrophy  of  the  uterus  arising  after  the 
menses  have  been  established.  I  have  had  occasion  to  use  it,  and  am 
now  employing  it  in  the  interesting  case  to  which  I  have  alluded  above. 
It  is  theoretically  better,  I  am  afraid,  than  it  will  be  found  practically  ; 
yet  no  doubt  much  good  may  be  done  by  it.  The  object  of  the  intra- 
uterine pessary  is  that  it  may  be  the  medium,  or  generator,  rather,  of 
galvanism,  to  stimulate  the  nerves  of  the  uterus. 

Both  of  these  effects  are  promotive  of  uterine  hemorrhage,  if  not  of 
correct  menstruation.  They  are  necessary  to  the  development  of  an 
atrophied  uterus,  whether  congenital  or  acquired.  But  this  instrument 
is  recommended  and  used  in  obstinate  cases  of  amenorrhoea,  where  there 
is  no  apparent  deficiency  in  the  size  and  development  of  the  organs 
concerned.  It  is  in  this  class  of  cases  that  most  may  be  effected  by  it, 
and  yet  it  sometimes  entirely  fails  to  produce  any  effect.  To  do  good 
in  the  cases  of  atrophy  and  want  of  development  it  should  be  used 
continuously.  Where  the  development  is  good,  I  am  inclined  to  think 
that  the  pessary  will  do  more  good  by  using  it  intermittingly.  In 
these  cases  we  may  introduce  the  instrument  one  week  before  the 
time  of  the  expected  period,  and  allow  it  to  remain,  and  then,  after  the 
time  is  passed,  remove  it,  and  again  introduce  it  at  the  proper  time. 
We  should  remember  that  we  cannot  use  an  instrument  of  the  same 
size  in  all  cases.  In  the  uterus  that  is  much  atrophied  it  would  be 
violence  to  use  an  instrument  that  is  applicable  to  a  fully  developed 
organ.  In  the  former  we  must  have  an  instrument  that  will  pass  into 
it  easily,  and  in  a  couple  of  months  use  one  larger;  and  after  the  lapse 
of  a  similar  time  make  another  one  still  larger,  etc.,  until  development 
is  complete.  The  instrument  is  made  of  copper  and  zinc,  and  consists 
of  a  stem  and  bulb.  The  bulb  is  hollow,  in  order  to  be  light  as  pos- 
sible, flattened,  and  oval  in  shape,  one  inch  long,  three-quarters  of  an 
inch  wide,  and  half  an  inch  thick.  It  should  be  perforated  through 
its  thinnest  diameter  by  a  hole  two-twelfths  of  an  inch  in  diameter. 
Into  this  perforation  the  stem  is  to  be  inserted.  .  The  stem  should  be 
two  inches  long  for  a  uterus  not  atrophied,  and  as  much  less  as  is 
necessary,  in  the  judgment  of  the  attendant,  when  atrophy  has  taken 
place.  It  should  be  hollow  and  light  like  the  bulb.  The  bulb,  and 
one  inch  of  the  stem  next  the  bulb,  is  made  of  copper,  the  extremity 
of  the  stem  of  zinc.  This  completes  the  instrument  as  made  and  used 
by  Professor  Simpson.  I  find',  in  some  instances,  great  difficulty,  if 
not  an  entire  impracticability,  in  wearing  it,  on  account  of  its  tendency 


296  AMENORRHCEA. 

to  fall  out.  Sometimes,  too,  the  galvanic  stimulus  is  not  sufficient.  On 
these  accounts  I  have  made  an  addition  to  it,  which,  I  think,  adds  to 
its  efficiency  as  well  as  to  security  of  position.  This  consists  of  a  zinc 
ball,  about  an  inch  in  diameter,  attached  to  a  copper  rod  four  inches 
long.  The  ball  is  introduced  into  the  vagina  after  the  intrauterine 
pessary  has  been  introduced,  while  the  stem  is  attached  to  a  frame- 
work outside  the  pelvis  to  keep  the  whole  in  position.  As  will  be  seen 
by  a  study  of  this  apparatus  we  have  quite  a  galvanic  battery,  the 
copper  rod  reaching  from  the  framework  of  zinc  outside  to  the  zinc 
ball  inside,  this  last  lying  in  contact  with  the  copper  bulb  of  the 
pessary,  etc.  If  we  do  not  desire  any  galvanism  the  whole  apparatus 
can  be  made  of  copper.  Made  in  this  way  the  instrument  is  quite 
efficient.  The  young  physician  or  student  may  be  embarrassed  in 
his  attempts  to  introduce  the  pessary  without  a  little  consideration. 
The  plan  I  have  found  most  convenient  is,  to  expose  the  os  uteri  by 
means  of  the  bivalve  speculum ;  secondly,  to  secure  the  pessary  by  in- 
serting a  piece  of  whalebone,  properly  shaped,  in  the  perforation  in 
the  bulb ;  thirdly,  thus  mounted,  to  insert  the  stem,  and  with  great 
gentleness  urge  it  forward  to  its  full  length,  or  until  it  is  arrested  by 
the  contracted  internal  os  uteri  or  the  end  touching  the  fundus.  If 
this  arrest  occurs  the  instrument  is  either  too  large  or  too  long,  and 
must  be  replaced  by  one  more  suitable  in  this  respect.  After  the  pes- 
sary is  inserted  we  may  withdraw  the  speculum,  and,  if  necessary, 
apply  the  ball  and  external  framework  above  described  to  keep  it  in 
position.  All  this  direction  does  not  include  a  fact  which  should  ever 
be  borne  in  mind  by  the  student,  viz.,  that  sometimes  the  instrument 
is  utterly  intolerable ;  and,  at  others,  a  good  deal  of  address  and  pa- 
tience is  required  to  habituate  the  parts  to  it.  The  patient  should  be 
forewarned  that  pain  and  inflammation  are  the  possible  effects,  and  that 
she  must  inform  us  should  they  be  considerable.  There  is  always  some 
pain,  sometimes  a  great  deal.  When  the  irritation  is  too  severe  the 
instrument  must  be  removed,  quietude  observed,  and,  if  necessary, 
anodynes,  and  even  antiphlogistic  treatment  must  be  resorted  to,  to 
remove  the  symptoms.  After  all  these  have  subsided  it  may  be  again 
introduced.  A  little  perseverance  and  care  will  render  most  cases 
tolerant  of  its  presence.  During  the  time  the  instrument  is  used  the 
vagina  must  be  thoroughly  cleansed,  at  least  twice  a  day,  with  tepid, 
warm,  or  cold  water,  and  fine  soap,  used  as  injections. 

For  the  treatment  of  Amenorrhoea  by  retention  the  reader  is  referred 
to  the  Treatment  of  Atresia  and  Absence  of  the  Vagina. 


CHAPTER  XL 

MENORRHAGIA  AND  METRORRHAGIA. 

Hemorbhage  occurring  at  the  time  of  menstruation  beyond  the 
usual  quantity  is  menorrhagia.  Hemorrhages  occurring  at  other  times 
do  not  belong  to  this  denomination,  but  are  called  metrorrhagia. 
Often  both  metrorrhagia  and  menorrhagia  occur  in  the  same  individual, 
which  depend  upon  the  same  conditions  of  the  system  or  reproduc- 
tive organs,  and  are  alike  symptomatic  of  some  local  or  general  dis- 
ease. 

It  is  not  difficult  to  understand  that  an  exaggeration  of  the  hyper- 
semia,  or  an  unusually  rapid  disintegration  of  the  uterine  mucous 
membrane,  would  cause  more  than  a  normal  amount  of  flow,  nor  that 
a  want  of  accordance  in  time  might  be  followed  by  the  same  result. 
Indeed  most  cases  of  uterine  hemorrhage  are  traceable  to  conditions 
which  disturb  the  equilibrium  of  these  phenomena.  The  causes  which 
thus  act  are  varied  and  numerous. 

Morbid  nervous  influences,  which  increase  the  discharge  of  blood  from 
the  uterus,  sometimes  emanate  from  the  nervous  centres,  and  hence 
may  be  properly  termed  centric;  much  more  frequently,  however,  they 
are  reflected  through  the  nervous  centres  from  other  and  sometimes 
distant  organs,  and  these  last  are  entitled  to  the  denomination  oi  reflex 
or  eccentric  nervous  influences. 

Mental  and  emotional  excitement  emanating  directly  from  the  brain, 
and  cerebral  and  spinal  excitement  originating  in  inflammation  or 
functional  exhaustion  of  the  brain  or  spinal  cord,  are  examples  of 
centric  etiological  influences.  Many  years  ago  I  witnessed  the  ravages 
of  an  epidemic  of  cerebro-spinal  inflammation,  in  which  uterine  hem- 
orrhage was  of  almost  universal  occurrence  among  those  adult  fe- 
males who  fell  under  its  influences. 

Morbid  reflex  nervous  influences  afford  a  more  numerous  class  of 
causes.  First  among  them,  both  in  frequency  and  importance,  are 
those  arising  from  abnormal  conditions  of  the  ovaries,  such  as  conges- 
tion, inflammation,  displacement,  and  erotic  excitement.  Next  to  the 
influence  of  these  bodies  is  that  exerted  by  the  mammary  glands. 
Menstruation  is  generally  more  profuse  when  it  occurs  during  lactation. 
The  effect  of  mammary  irritation  in  causing  congestion  of  the  uterus, 
and  thus  promoting  hemorrhage  from  it,  is  well  illustrated  by  the 
familiar  fact  that  sinapisms  or  blisters  applied  to  the  breast  will  often 
cause  metrorrhagia.  Vesical  irritation,  or  inflammation,  which  gives 
rise  to  tenesmus,  rectal  irritation,  as  from  the  presence  of  hemorrhoids 


298  MENOERHAGIA    AND    METRORRHAGIA. 

or  ascarides,  and  dysenteric  inflammation,  through  the  reflex  influence 
which  they  exert  upon  the  uterus,  are  generally  recognized  causes  of 
uterine  hemorrhage.  Among  other  reflex  causes  may  be  mentioned 
certain  forms  of  indigestion,  hepatic  congestion  and  inflammation,  and 
some  of  the  disturbances  of  the  small  intestines,  as  may  also  strong 
impressions  upon  the  cutaneous  surface,  as  from  cold,  or  from  the 
long-continued  application  of  heat  in  warm  climates  and  seasons. 

All  of  these  last-mentioned  causes  I  think  act  through  the  reflex 
system  of  spinal  nerves,  and  perhaps  also  through  the  agency  of  the 
sympathetic  ganglia,  which  perform  a  reflex  function  between  the 
viscera.  The  morbid  effects  of  the  various  reflex  nervous  impressions 
are  rendered  more  effective  and  intense  by  the  presence  of  such  uterine 
diseases  as  predispose  to  hemorrhage  by  increasing  the  vascularity  of 
the  uterus. 

Many  'pathological  conditions  which  conduce  to  the  production  of 
uterine  hemorrhage,  independently  of  direct  nervous  influence,  act  by 
increasing  the  hypergemia  of  the  uterus.  When  the  mucous  membrane 
is  granulated,  or  is  the  seat  of  inflammation,  of  fibrous  polypus,  or  of 
malignant  fungus,  the  circulation  of  the  uterus  is  increased,  and  har- 
mony in  the  process  of  nidation  disturbed ;  and  these  conditions  will 
be  accompanied  by  an  unusual  and  long-continued  flow  of  blood. 
Subinvolution,  congestion  and  inflammation,  hyperplasia,  tuberculosis, 
cancerous  and  fibrous  deposits  in  the  muscular  structure,  and  chronic 
and  acute  endometritis,  in  addition  to  preventing  the  normal  decidu- 
ous changes  in  the  mucous  membrane  of  the  uterus,  maintain  a  per- 
manent hj'perffimia,  and  thus  render  the  womb  prone  to  large  losses  at 
each  return  of  the  menstrual  period.  We  have,  in  fact,  abundant  rea- 
sons for  assuming  that  chronic  hyperjemia,  no  matter  how  produced, 
will,  by  virtue  of  the  malnutrition  connected  with  it,  prevent  menstrual 
changes  from  being  effected  in  an  orderly  manner,  and  thus  render 
the  mucous  membrane  more  frail  in  organization,  and  consequently 
incapable  of  resisting  the  force  of  vascular  pressure  to  which  it  is 
periodically  subjected. 

Besides  the  causes  of  uterine  hypersemia  last  alluded  to,  and  exist- 
ing within  the  tissues  of  the  womb,  there  are  many  other  outside  •patho- 
logical conditions  acting  in  a  different  way.  Some  of  these  cause  venous 
hypergemia  by  mechanical  retardation  of  the  circulation,  while  others 
give  rise  to  both  arterial  and  venous  hypera?mia  by  nutritional  attrac- 
tion, and  others  again  cause  arterial  hyperemia  alone,  by  forcing  un- 
usual amounts  of  blood  into  the  organ.  Among  the  most  frequent 
and  important  causes  of  venous  retardation  are  displacements  and 
flexions  of  the  uterus — procidentia,  retroversion,  and  retroflexion — 
the  former  by  stretching  the  veins  and  rendering  their  course  more 
tortuous,  the  latter  by  twisting  them,  and  thus  lessening  their  calibre ; 
exudations  into  the  cellular  tissue  and  peritoneal  pouch,  from  cellulitis 


CAUSES   OF    MENORRHAGIA.  299 

and  local  peritonitis,  and  effusions  of  blood  in  the  cul-de-sac  of  Doug- 
las, in  retro-uterine  hsematocele,  by  pressing  upon  the  veins,  prevent  a 
free  return  of  blood  from  the  uterus,  and  thus  cause  venous  hypersemia. 
Retardation  of  movement  in  the  uterine  veins  may  also  be  caused  by 
obstruction  to  the  venous  circulation  quite  remote  from  the  womb,  as 
by  the  pressure  of  a  tumor  upon  the  ascending  vena  cava,  by  a  loaded 
condition  of  the  large  intestine,  by  dislocation  or  enlargement  of  the 
liver,  by  obstruction  to  the  free  passage  of  blood  through  the  heart  from 
vulvular  disease,  and  even  by  certain  pulmonary  affections. 

In  the  class  of  causes  giving  rise  to  both  arterial  and  venous  hyper- 
semia  may  be  mentioned  fibrous,  fibrocystic,  polypoid,  and  fungous 
growths  of  the  fibrous  structure  of  the  uterus.  These  all  increase  the 
flow  of  blood  to  and  through  the  vessels  of  the  uterus,  both  arteries 
and  veins  are  increased  in  capacity,  and  to  these  changes  is  added 
general  hypertrophy.  In  these  cases  the  hypersemia  of  all  the  tissues 
is  sometimes  enormously  great,  and  the  losses  of  blood  are  propor- 
tionally large  and  dangerous ;  the  hemorrhage,  unlike  that  from  venous 
obstruction,  is  not  checked  by  the  emptying  of  the  vessels,  but  contin- 
ues until  the  arterial  and  cardiac  vis-a-tergo  is  weakened  by  approach- 
ing syncope. 

Causes  producing  arterial  hypersemia  alone  are  hypertrophy  of  the 
heart,  general  plethora,  febrile  excitement,  and  violent  exercise.  The 
uterine  hypersemia  in  these  cases  is  caused  by  unusual  arterial  and 
cardiac  pressure  alone.  When  not  attended  by  local  pathological  con- 
ditions, the  hemorrhage  in  these  cases  is  not  apt  to  be  serious. 

Other  not  uncommon  causes  of  hemorrhage  from  the  womb  are  vari- 
ous diseases  of  the  blood.  Among  these  may  be  mentioned  scurvy,  leu- 
cocythffimia,  chlorosis,  albuminuria,  and  syphilis.  It  is  not  likely  that 
the  vice  in  the  composition  of  the  blood  is  the  sole  causative  influence 
operating  in  the  above  named  conditions.  In  scurvy,  for  instance,  we 
know  that  the  solid  tissues,  whether  as  a  primary  condition  or  as  an 
effect  of  the  blood-changes,  are  diseased,  the  capillaries  more  fragile 
than  natural,  and,  consequently,  less  capable  of  resisting  the  cardiac 
impulse.  As  evidence  that  the  vicious  condition  of  both  blood  and  solid 
tissues  is  the  cause  of  uterine  hemorrhage  in  scurvy,  the  well-known 
fact  may  be  added  that  bleeding  is  very  easily  provoked  in  other  mu- 
cous membranes.  It  is  the  more  likely  to  take  place  from  the  mucous 
membrane  of  the  uterus,  because  of  the  great  normal  fluctuations  in 
the  circulation  of  that  organ,  and  also  because  the  vitiated  state  of  the 
blood  would  naturally  cause  disturbance  in  other  conditions  attendant 
upon  menstruation,  especially  the  decidual  changes.  It  will  be  seen 
therefore  that  the  peculiarity  in  the  operation  of  this  variety  of  cause 
is  not  due  to  the  presence  of  local  or  general  hj^persemia  from  retarda- 
tion of  the  venous  circulation,  or  from  arterial  and  cardiac  pressure, 
but  is  due  to  the  tendency  of  the  blood  to  escape  through  the  walls  of 


300  MENORRHAGIA   AND   METRORRHAGIA. 

the  vessels,  and  to  the  inability  of  the  capillar}^  tubes  to  resist  the  cir- 
culatory force  ordinarily  applied  to  them. 

As  another  cause  of  hemorrhage  from  the  womb  must  be  mentioned 
the  well-known  law  of  the  human  system,  to  continue  a  long-established 
hahit  after  the  original  cause  is  removed.  This  is  probably  the  only 
rational  explanation  of  those  rare  uterine  losses  which  are  sometimes 
observed  in  pregnancy  and  in  cases  where  both  ovaries  have  been  re- 
moved. The  habit  of  bleeding  continues  after  the  ovarian  reflex  ner- 
vous influence  has  been  withdrawn  from  the  uterus. 

Still  another  rare  yet  very  dangerous  cause  of  uterine  hemorrhage  is 
that  known  to  surgeons  as  the  hemorrhagic  diathesis.  The  writer  has 
seen  one  case  in  which  he  believes  that  the  bleeding  was  clearly  at- 
tributable to  this  mysterious  condition,  and  which  proved  fatal.  It 
was  that  of  a  young  girl  who  died  with  her  second  menstrual  flow. 

The  wide  range  of  causative  conditions  found  connected  with  uterine 
hemorrhage  is  but  an  inverse  exhibition  of  the  sympathetic  relations 
of  the  uterus.  When  diseased,  it  exercises  an  almost  universal  patho- 
logical influence  upon  other  organs,  and,  as  a  consequence,  it  is  sus- 
ceptible of  being  impressed  to  the  same  degree  by  certain  morbid 
conditions  of  all  important  viscera.  It  will  not  be  regarded  as  making 
an  undue  claim  to  say  that  the  practice  of  gynecology  requires  a  more 
thorough  theoretical  and  practical  familiarity  with  the  details  of  all 
the  branches  of  medicine  than  any  other  of  the  so-called  specialties. 
We  are  not  prepared  to  treat  the  most  common  of  female  diseases 
without  being  able  to  scan  with  scientific  scrutiny  every  organ  and 
function  of  the  body.  Nor  until  we  can  compete  successfully  with 
the  general  practitioner,  the  surgeon,  the  alienist,  and  the  neurologist 
in  the  therapeutic  processes  of  their  respective  departments  may  we 
hope  to  exercise  in  the  highest  sense  the  office  of  the  gynecologist. 
These  remarks  apply  with  force  to  the  comprehension  of  the  causes 
and  treatment  of  hemorrhages  of  the  unimpregnated  and  non-puer- 
peral uterus. 

Treatment  of  Menorrhagia. 

I  find  it  quite  impossible  to  satisfy  mj^self  as  to  the  best  order  in 
which  to  bring  forward  the  various  measures  proposed  for  treating 
uterine  hemorrhage.  Those  which  have  for  their  object  the  removal 
of  the  causing  conditions,  properly  fall  under  the  head  of  curative 
means ;  while  those  which  we  employ  to  stop  the  bleeding  tempo- 
rarily, until  the  remedies  of  the  first  order  have  accomplished  their 
purpose,  seem  as  naturally  to  belong  to  the  category  of  'palliative 
measures.  We  find  in  each  of  these  divisions,  however,  remedies 
which  act  in  both  ways,  and  the  palliative  means  are  often  radical 
and  energetic.  Notwithstanding  the  many  obvious  deficiencies  in 
this  arrangement,  it  seems  to  me  to  be  the  best  that  I  can  adopt. 


TREATMENT  OF  MENORRHAGIA.  301 


Palliative  Treatment. 


Before  entering  into  a  detailed  description  of  the  more  essential 
remedial  methods  of  curing  the  various  forms  of  hemorrhage  it  will 
be  profitable  to  consider  some  of  the  important  minor  measures  which 
are  applicable  in  almost  all  instances.  As  the  great  majority  of 
hemorrhages  occur  at  the  menstrual  periods,  we  often  have  oppor- 
tunities of  adopting  measures  in  anticipation  of  them.  These  meas- 
ures are  sometimes  calculated  to  entirely  prevent  an  exaggerated  flow, 
and  at  others  to  very  much  modify  it ;  and  in  all  to  greatly  promote 
the  action  of  more  direct  remedies.  The  patient  should  abstain  from 
all  causes  of  local  or  general  vascular  or  nervous  excitement.  *  Among 
these  causes  are  mental  and  bodily  fatigue,  emotional  excitement 
arising  from  certain  social  relations,  sensational  books,  and  the  con- 
templation of  erotic  objects.  The  patient  should  also  abstain  from 
stimulating  drinks  and  highly  seasoned  food ;  her  clothing  should  be 
loose  and  cool,  so  that  no  part  of  the  body  may  be  constricted,  and 
the  genital  organs  should  not  be  too  warmly  covered.  Her  bowels 
ought  to  be  kept  regular,  or  rather  free.  The  secretions  from  the  skin, 
liver,  and  kidneys  should  be  maintained  as  nearly  as  possible  in  a 
normal  condition,  and  tonics,  such  as  arsenic,  strychnia,  and  quinia, 
with  digestible,  nourishing,  and  unstimulating  diet,  should  be  given 
in  quantities  sufficient  to  keep  the  health  up  to  the  normal  standard. 
Other  things  which  will  contribute  very  greatly  to  good  results  are 
plenty  of  pure  air,  night  and  day,  and  moderate  muscular  exercise. 
Many  other  general  directions  will  suggest  themselves,  which  I  cannot 
stop  now  to  mention. 

When  the  time  for  the  paroxysm  has  arrived,  and  the  hemorrhage 
has  commenced,  isolation,  quietude,  and  recumbency  are  very  im- 
portant precautions  to  be  enjoined.  Position,  indeed,  may  be  made 
to  do  much  good  of  itself.  If  the  hemorrhage  is  not  severe,  mere 
recumbency  will  be  sufficient;  but  if  it  is  protracted,  the  hips  should 
be  elevated,  and  sometimes  it  will  be  beneficial  to  raise  them  so  high 
as  to  cause  the  blood  to  gravitate  to  the  fundus  uteri,  and  to  fill  the 
whole  genital  canal  before  any  of  it  passes  out.  To  a  considerable 
extent  this  may  be  made  to  act  as  a  tampon.  The  position  chosen  to 
effect  this  object  may  be  on  the  back,  or  upon  the  knees  and  chest. 
If  the  latter  position  can  be  commanded,  it  is  much  the  best,  as  the 
reversal  of  gravitation  is  more  complete.  Cold  and  acid  drinks,  cold 
applications  to  the  hypogastric  and  sacral  regions,  hips,  and  vulva, 
and  in  the  vagina,  are  also  among  the  remedies  suitable  to  almost 
all  cases.  Many  practitioners  value  astringents,  administered  in- 
ternally, in  uterine  hemorrhage,  but  I  have  found  so  little  benefit 
from  them  when  not  given  with  opium  or  belladonna,  that  I  seldom 
resort  to  them.  Where  there  is  much  pain  in  the  pelvis,  and  a  dry 
state  of  the  skin,  opium  and  ipecacuanha  are  often  very  serviceable. 


302  MENORRHA&IA    AND    METRORRHAGIA. 

Lobelia,  gelseniium,  digitalis,  aconite,  and  veratrum  viride,  may  also 
be  mentioned  as  very  frequently  applicable  where  there  is  vascular 
and  nervous  excitement. 

Perhaps  the  medicine  most  generally  applicable  in  paroxysms  of 
uterine  hemorrhage,  is  ergot.  In  all  cases  of  local  arterial  hypersemia, 
as  in  tumors,  hyperinvolution,  etc.,  we  may  expect  good  from  its 
employment.  But  it  will  generally  fail  to  be  useful  when  the  uterine 
hypereemia  is  venous,  as  in  retroversion,  pelvic  infarction  from  peri- 
uterine effusion,  abdominal  tumors,  etc.  It  will  not  act  efficiently  in 
cases  of  carcinomatous  deposit,  granulations  of  the  mucous  membrane, 
or  tuberculous  degeneration  of  the  fibrous  texture  of  the  uterus. 

In  the  more  dangerous  instances  of  hemorrhage,  these  moderate 
palliative  measures  are  not  sufficient.  In  some,  the  amount  of  loss  is 
so  great,  and  occurs  so  suddenly,  as  to  threaten  the  life  of  the  patient. 
Or,  if  life  be  not  in  danger,  the  discharge  may  be  sufficient  to  lead  to 
other  very  serious  remote  consequences.  These  emergencies  are  to  be 
met  by  such  means  as  will  promptly  arrest  the  flow,  and  keep  it  in 
check  until  curative  processes  can  be  instituted.  Fortunately  this 
may  be  clone  with  great  certainty  by  mechanical  and  chemical  appli- 
ances generally  at  our  command.  The  genital  canal,  practically  closed 
at  its  upper  extremity,  and  conveniently  open  at  its  lower  termination, 
admits  of  being  impacted  to  an  impermeable  degree,  and  allows  of 
topical  applications  to  its  whole  extent.  In  using  either  form  of  these 
topical  measures,  the  effort  should  be  made  to  apply  the  remedy  as 
near  to  the  bleeding  point  as  possible. 

When  practicable,  we  may  secure  the  best  effects  by  employing  the 
mechanical  and  chemical  means  conjointly.  The  mechanical  means 
embrace  the  different  forms  of  the  tampon.  Plugging  arrests  the 
hemorrhage  by  forcibly  opposing  the  evacuation  of  the  blood,  and  b}'' 
thus  imprisoning  it  in  the  smallest  cavity.  The  blood  so  confined, 
coagulates,  and  fills  the  space  between  the  tampon  and  the  bleeding 
surface  with  a  fibrinous  clot,  which  also  closes  the  mouths  of  the 
vessels.  When  plugging  is  skilfully  performed,  the  relief  is  tempo- 
rarily perfect,  and  gives  us  valuable  time  for  other  treatment,  or  allows 
the  cyclical  period  to  pass,  when  the  hypersemia  subsides.  The  chemical 
means  consist  in  the  use  of  powerful  haemostatics.  By  their  chemical 
action  upon  the  solid  constituents  of  the  blood,  the}"  produce  a  much 
firmer  coagulum  than  results  from  mere  stasis,  and,  if  applied  to  the 
ruptured  vessels,  seal  them  up  with  coagulated  plastic  material,  while 
if  further  away  the  coagulum  forms  a  chemical  tampon  which  opposes 
the  flow  toward  the  vulva.  Used  with  the  mechanical  tampon  they 
may  be  made  to  fill  the  interstices  of  the  material  of  which  it  is  formed, 
and  thus  solidify  the  whole  mass. 

In  the  greater  number  of  dangerous  cases  of  the  kind  of  uterine 
hemorrhage,  the  mouth  of  the  womb  is  sufficientl}"  patent  to  permit 


TREATMENT  OF  MENORRHAGIA.  303 

the  introduction  of  the  plugging  material  saturated  with  a  haemostatic 
preparation  into  the  cavity  of  the  uterus.  Dr.  Sims's  method  of  pre- 
paring the  material  and  performing  the  operation  of  plugging  the 
womb  is  admirable  in  its  simplicity  and  efficiency.  The  substance 
used  is  the  finest  article  of  cotton -wool,  saturated  with  a  liquid  com- 
posed of  one  part  of  the  strong  solution  of  the  subsulphate  of  iron  and 
two  of  water.  After  the  cotton  has  been  perfectly  saturated,  it  is  de- 
prived of  the  major  part  of  its  fluid  by  pressure,  and  is  then  allowed 
to  dry  until  ready  for  use.  The  application  is  made  by  wrapping  a 
sufficient  quantity  of  the  dried  iron-cotton  around  a  long,  small  piece 
of  whalebone,  and  introducing  it  into  the  cavity  of  the  uterus,  Avhen 
the  cotton  is  detached  and  left  there.  If  the  hemorrhage  is  compara- 
tively moderate,  one  of  these  pieces  may  be  sufficient ;  if  severe,  it  will 
be  necessary  to  stuff  the  uterine  cavity  full.  This  can  be  best  accom- 
plished by  having  the  patient  placed  on  her  side,  and  the  uterus  ex- 
posed by  Sims's  speculum.  To  facilitate  the  removal  of  this  ferruginous 
tampon,  the  suggestion  of  Dr.  J.  R.  Chadwick,  of  Boston,  is,  I  think,  a 
valuable  one,  viz.,  to  wrap  strong  thread  loosely  around  the  cotton  as 
it  surrounds  the  whalebone.  I  prefer  this  method  of  using  the  haemos- 
tatic to  its  injection,  because  the  shock  from  the  application  is  much 
less. 

If  the  mouth  and  cervical  cavity  of  the  womb  are  not  sufficiently 
open  to  permit  of  the  introduction  of  this  haemostatic  preparation,  we 
may  plug  the  cervix  with  prepared  sponge.  The  first  sponge  should 
'be  pushed  through  the  cervix  into  the  cavity,  and  up  to  the  fundus 
uteri,  so  that  when  it  expands  its  upper  end  may  possibly  reach  and 
press  upon  the  bleeding  point.  If  large  enough,  the  cervical  cavity 
Avill  be  completely  filled  and  the  bleeding  effectually  checked.  The 
sponge  should  be  carbolized,  and  well  secured,  before  it  is  introduced, 
by  passing  a  strong  piece  of  twine  through  it,  from  one  end  to  the 
other.  Neither  the  cotton  nor  sponge  should  be  allowed  to  remain 
longer  than  twenty-four  hours,  and  half  of  that  time  is  usually  long 
enough.  After  removal,  the  vagina  may  be  cleansed,  and  the  applica- 
tion repeated  if  necessary.  I  have  sometimes  been  obliged  to  renew 
the  sponge  tampon  several  times  in  the  same  case,  though  this  is  not 
usually  required. 

If  these  means  are  not  at  hand,  or  if  the  case  is  not  sufficiently 
urgent  to  require  plugging  of  the  uterus,  we  may  resort  to  the  vaginal 
tampon.  This  may  be  made  of  cotton,  of  which  pieces  as  large  as 
pullet's  eggs  may  be  used,  rolled  somewhat  solidly,  and  each  secured 
with  thread  and  lubricated  with  oil  or  lard.  A  sufficient  number  to 
perfectly  fill  the  vagina  should  be  prepared.  The  patient  should  be 
placed  on  her  leftside,  with  the  limbs  flexed,  and  the  upper  one  thrown 
forward  over  the  other.  The  operator,  standing  at  the  back  of  the 
patient,  inserts  into  the  vagina  two  fingers  of  the  left  hand,  with  which 


304  MENORRHAGIA  AND  METRORRHAGIA. 

he  draws  the  perineum  well  backward.  This  will  open  the  canal  so  that 
the  clots  may  be  easily  removed  with  the  fingers,  when,  with  the  right 
hand,  the  cotton  balls  may  be  placed  in  the  vagina  with  great  facility ; 
at  first  several  on  the  os  and  around  it,  and  then  the  whole  vagina  may 
be  packed  solidly  under  the  eye  of  the  operator.  If  Sims's  speculum 
be  at  hand,  it  should  be  used  instead  of  the  two  fingers  to  hold  back 
the  perineum.  Or  we  may  vary  this  according  to  the  process  described 
by  Dr.  Thomas  in  the  American  Journal  of  the  Medical  Sciences  for  July, 
1876,  page  147.  After  dilating  the  vagina,  "  pieces  of  cotton,  soaked 
in  water,  pressed  and  flattened  out  by  the  fingers,  each  about  the  size 
of  a  very  small  biscuit,  are  pressed  into  the  vaginal  cul-de-sac  by 
means  of  the  forceps  till  this  is  filled.  Then  other  pieces  are  packed 
firmly  around  the  cervix  until  only  the  os  is  visible ;  a  smaller  pad  is 
then  pressed  firmly  against  or  introduced  within  the  cervical  canal, 
and  the  whole  vagina  is  then  filled  to  its  lowest  portion."  An  ordi- 
nary surgeon's  roller  answers  admirably  for  a  plug,  and  may  be  intro- 
duced by  first  inserting  one  end,  and  then  passing  it  up  in  short  folds 
until  enough  has  been  placed  in  the  vaginal  cavity  to  fill  it  up  com- 
pactly. In  most  cases,  where  we  desire  to  leave  the  patient,  the  tampon 
should  be  retained  by  a  compress  and  "  T  "  bandage. 

When  we  have  reason  to  anticipate  a  sudden  occurrence  of  severe 
hemorrhage  in  our  absence,  we  may  instruct  the  patient  or  nurse  how 
to  make  and  apply  a  very  safe  vaginal  plug.  A  sponge,  large  enough 
to  fill  the  vagina  closely,  may  be  prepared  by  wetting  it  in  a  strong  so- 
lution of  alum,  or  in  a  weak  solution  of  subsulphate  of  iron,  passing 
a  piece  of  strong  twine  or  tape  through  the  centre,  and  then  wrapping 
it  with  tape  in  an  elongated  shape  to  its  smallest  dimensions.  It  may 
then  be  laid  aside  to  dry.  When  the  necessity  for  its  use  arises  the 
tape  is  removed,  and  the  sponge  thus  compressed  may  be  passed  with- 
out any  resistance  entirely  into  the  vagina.  It  is  soon  expanded  by 
the  blood,  and  the  vaginal  cavity  thoroughly  filled.  A  few  of  these 
sponges  prepared  ready  for  instant  use  will  enable  the  patient  to  pre- 
vent any  material  loss  until  the  practitioner  arrives.  The  plug  may 
be  removed  by  the  tape  or  twine  whenever  desired.  The  plug  may 
be  allowed  to  remain  from  eighteen  to  twenty-four  hours,  when  it 
should  be  withdrawn,  and  the  vagina  having  been  thoroughly  cleansed 
with  carbolized  water,  replaced  if  necessary. 

Curative  Treatment. 

The  central  nervous  disorders  which  cause  uterine  hemorrhage  will, 
when  recognized,  require  the  treatment  set  forth  in  the  various  works 
upon  these  subjects.  I  need  not,  therefore,  dwell  here  upon  the  man- 
agement of  the  spinal  and  cerebral  inflammations  and  irritations,  nor 
upon  the  numerous  forms  of  emotional  excitement  which  lead  to 
metrorrhagia.   The  treatment  of  the  reflex,  morbid,  nervous  influences 


TREATMENT  OF  MENORRHAGIA.  305 

belongs  more  particularly  to  gynecolog}^,  and  will  call  for  all  the  in- 
genuity and  varied  knowledge  taught  in  that  branch  of  practical  medi- 
cine. The  ovarian  derangements,  being  the  more  obvious  and  common 
of  these  may  be  noticed  first.  Our  means  for  replacing  and  retaining 
in  position  displaced  ovaries  are  very  meagre.  The  patient  must  be 
confined  to  the  horizontal  position,  with  the  pelvis  elevated  as  much 
as  practicable.  The  knee-chest  position  is  the  best,  and  may  often  be 
maintained  for  a  considerable  part  of  the  twenty-four  hours.  Generally 
the  displacement  is  accompanied  by  congestion  or  inflammation  of 
the  ovary,  which  increases  its  size  and  weight.  When  this  is  the  case, 
the  treatment,  in  addition  to  position  and  quietude,  recommended 
during  the  intermenstrual  period,  will  consist  in  the  use  of  counter- 
irritants,  hip-baths,  hot-water  vaginal  injections,  and  alteratives,  ad- 
ministered internally,  or  applied  externally  in  the  form  of  ointments 
or  per  vaginam  as  suppositories,  injections,  etc.  Among  the  altera- 
tives, the  muriate  of  ammonia  will  be  found  very  valuable.  When 
there  is  much  debility,  the  bichloride  of  mercury,  dissolved  in  the  com- 
pound tincture  of  cinchona,  is  among  the  very  best.  Iodine,  iodide  of 
potassium,  and  iodide  of  iron  should  also  be  named  as  efficient  altera- 
tives in  these  conditions  of  the  ovaries.  One  derivative  measure  which 
I  desire  to  mention  as  especially  beneficial  in  these  cases  is  dry  cup- 
ping over  the  sacrum,  often  repeated.  To  be  effectual  the  cups  should 
be  large  and  allowed  to  remain  for  a  long  time,  say  an  hour  or  n;!ore. 
When  there  is  much  pain  in  the  ovarian  regions,  suppositories  of  the 
,  extract  of  belladonna  and  ergot,  once  or  twice  daily,  will  not  only  re- 
lieve the  pain,  but  will  do  much  towards  allaying  the  inflammation. 

When  hemorrhage  occurs  in  a  nursing  woman,  if  it  is  of  sufficient 
gravity,  the  child  should  be  weaned.  At  the  time  of  the  paroxysm, 
if  the  breasts  are  tumid  and  tender,  cold  may  be  applied  to  them  to 
relieve  both  the  uterine  hemorrhage  and  the  mammary  congestion. 
These  patients  require  invigorating  measures  in  connection  with  the 
local  treatment  of  the  breasts. 

The  vesical  or  rectal  tenesmus  which  gives  rise  to  hemorrhage  must 
be  treated  by  the  remedies  found  necessary  after  investigating  the  cause. 
So  also,  with  diseases  of  the  stomach,  bowels,  and  liver,  as  well  as  with 
the  effect  of  cold  or  of  long-continued  heat. 

Subinvolution  and  chronic  congestion  of  the  whole  uterus  require 
a  treatment  very  much  alike,  the  application  of  such  remedies  as 
condense  the  uterine  tissues, — ergot,  belladonna,  quinia,  electricity, 
cold  injections,  compresses,  and  sitz-baths.  When  there  is  no  tender- 
ness, ergot  will  be  found  a  very  efficient  remedy,  if  administered  for  a 
sufficient  length  of  time — several  months,  for  instance.  If  there  be 
considerable  tenderness  and  pain,  belladonna  and  quinia  will  be  best 
adapted  to  the  case.  Ergot  in  some  instances  induces  sensitiveness  and 
heat  in  the  pelvic  organs,  and  then  it  should  be  used  very  cautiously. 

20 


306  MENORRHAGIA    AND    METRORRHAGIA. 

This  effect  of  ergot  is  especially  noticeable  when  there  is  chronic  local 
peritonitis  or  cellulitis.  If  there  is  a  high  degree  of  sensitiveness,  a 
mercurial  alterative  may  very  properly  be  given  in  connection  with 
the  belladonna  and  quinia.  A  good  form  for  administering  it  is  the 
bichloride  of  mercury  dissolved  in  the  compound  tincture  of  cinchona; 
or  we  may  use  mercurial  inunction,  or  mercury  in  suppositories.  I 
have  not  been  able  to  do  much  good  in  these  cases  with  iodine  in  any 
form.  If  given  with  iron,  as  the  iodide  of  iron,  it  has  occasionally  a 
good  tonic  and  alterative  influence.  These  conditions  of  the  uterus 
are  very  obstinate,  and  require  a  continuous  treatment,  oftentimes  for 
many  months. 

The  treatment  of  endometritis,  described  elsewhere,  consists  mainly 
in  a  persevering  continuance  of  stimulating  applications  to  the  dis- 
eased mucous  membrane.  I  do  not  like  the  term  caustic  application, 
for  even  the  strongest  remedies  used  for  this  purpose  are  applied  so 
sparingly  that  their  effects  are  little  more  than  strongly  stimulative. 
In  the  light  of  our  present  knowledge  of  the  processes  of  menstrua- 
tion, these  remedies,  as  suggested  by  Dr.  Atthill,  should  be  resorted  to 
immediately  after  the  monthly  flow  has  ceased.  By  common  consent 
of  the  profession,  in  this  country,  the  treatment  of  granulations  of  the 
uterine  mucous  membrane  consists  in  scraping  them  off.  If  the 
mouth  of  the  uterus  be  sufficiently  patent  to  admit  a  small-sized  curette, 
the  scraping  may  be  done  effectually  without  dilatation ;  if  not,  a 
tupelo,  or  sea-tangle  tent,  may  precede  it. 

The  curette  should  be  passed  over  every  point  in  the  uterine  cavity 
with  firmness  enough  to  detach  the  soft  excrescences,  and  yet  there 
should  not  be  force  enough  employed  to  wound  the  natural  tissue.  Suc- 
cess will  generally  be  announced  by  the  discharge  of  the  soft  elongated 
growths.  These  are  sometimes  very  abundant.  The  scraping  should 
be  done  during  the  flow.  It  is  not  necessary  to  wait  for  a  protracted 
paroxysm  to  pass  by. 

Although  not  curative,  the  same  treatment  may  be  mentioned  as 
most  efficacious  in  arresting  the  hemorrhages  resulting  from  cancerous 
granulations.  In  a  discussion  of  Dr.  Hanks'  recent  paper.  Dr.  Peaslee 
gives  the  very  judicious  advice  not  to  cut  into  the  sound  tissue  in  the 
process.  In  cases  of  malignant  fungus,  we  may  often  arrest  the  ten- 
dency to  hemorrhage  by  injecting  alcohol,  by  means  of  a  hypodermic 
syringe,  deeply  into  the  substance  of  the  part.  This  process  frequently 
repeated  sometimes  retards  the  growth  very  materially.  The  tincture 
of  the  chloride  of  iron,  similarly  used  will  often  have  the  same  effect. 

The  various  conditions  which  give  rise  to  retardation  of  the  venous 
circulation  require  to  be  treated  according  to  the  improved  methods 
now  so  well  understood  by  the  profession.  The  displacements  of  the 
uterus,  which  are  arranged  among  these  conditions,  must  be  corrected 
by  the  various  ingenious  appliances  designed  for  this  j)urpose.     And 


TREATMENT  OF  MENORRHAGIA.  307 

this  may  be  done  during  the  time  of  the  preternatural  flow  with  the 
expectation  of  moderating  it  at  once. 

Dr.  T.  D.  Fitch,  of  Chicago,  has  recently  proven  this  last  assertion 
in  the  management  of  a  case  occurring  in  a  patient  who  had  just  passed 
the  menopause.  The  uterus  was  retroverted,  and  all  the  means  re- 
sorted to  did  not  even  moderate  the  metrorrhagia  until  the  organ  was 
elevated  and  retained  in  position  by  an  appropriate  pessary,  when  in  a 
short  time  the  bleeding  ceased.  After  the  subsidence  of  the  flow,  the 
patient  removed  the  instrument,  on  account  of  some  slight  inconven- 
ience which  it  gave  her,  but  the  flooding  began  again  in  a  very  few 
hours,  and  continued,  notwithstanding  repeated  eff'orts  to  arrest  it,  until 
the  pessary  was  once  more  introduced,  when  the  hemorrhage  again 
subsided,  and  did  not  return. 

The  extreme  danger  from  hemorrhage  connected  with  fibrous  tumors 
of  the  uterus  is  not  so  often  encountered  since  the  profession  has  be- 
come acquainted  with  the  great  influence  exerted  upon  certain  condi- 
tions of  the  unimpregnated  uterus  by  ergot.  It  is  now  understood 
that  fully  seventy-five  per  cent,  of  hemorrhagic  cases  of  fibrous  tumor 
of  the  uterus  may  be  rendered  free  from  danger,  as  far  as  the  hemor- 
rhage is  concerned,  by  an  intelligent  and  persevering  use  of  ergot,  and 
that  in  twenty  per  cent,  the  tumors  may  be  removed.  In  using  ergot^ 
in  these  cases,  the  mode  of  administering  it  cannot  be  uniform.  Some 
patients  cannot  take  it  in  any  sufficient  doses  to  answer  the  purpose  ; 
some  cannot  take  it  in  the  form  of  fluid  extract,  or  wine,  but  can  take 
the  solid  extract  in  the  form  of  pills  ;  others  can  take  it  in  any  form. 
When  the  stomach  will  not  tolerate  the  ergot,  it  may  be  given  hypo- 
dermically,  or  per  rectum  in  suppositories,  and  I  believe  that  it  can  be 
made  to  act  efficiently  when  given  in  any  of  these  ways. 

Whatever  method  or  form  we  may  adopt  in  the  aaministration  of 
ergot,  we  should  give  it  in  sufficient  quantities  to  produce  a  sensible 
efl'ect  by  causing  contractions  and  pain,  and  there  is  no  better  rule  to 
guide  us,  so  far  as  I  can  judge,  than  to  give  it  in  increasing  doses 
until  that  result  follows.  Twenty  minims  of  the  fluid  extract,  three 
times  a  day,  will  sometimes  be  sufficient,  while  some  patients,  on  the 
other  hand,  will  require  twice  or  three  times  as  much  to  produce  the 
effect. 

The  length  of  time  required  to  obtain  the  ultimate  effects  of  the 
ergot  in  these  doses  varies  as  much  as  the  quantity  required.  The 
tumor  will  sometimes  diminish  very  rapidly,  but  generally  the  decrease 
in  size  is  quite  slow.  From  one  month  to  over  a  year  may  be  required 
to  accomplish  a  cure  when  it  can  be  accomplished  at  all.  Ergot  is 
sometimes  very  violent  in  its  action,  but  by  withdrawing  it  tempor- 
arily, lessening  the  dose,  or  combining  and  alternating  it  with  ano- 
dynes, it  may  be  safely  managed.  Although  I  have  given  it  exten- 
sively, and  for  a  long  time  together,  I  have  not  seen  anything  worse 
than  inconvenience  arising  from  its  use. 


CHAPTEEXIL 

DYSMENORKHOEA. 

This  is  a  general  term  for  painful  and  difficult  menstruation,  and 
includes  conditions  widely  different  in  their  nature.  In  some  cases 
no  appreciable  morbid  changes  are  discoverable  in  the  organs  which 
seem  to  be  the  seat  of  pain,  either  during  or  between  the  times  of  the 
menstrual  flow.     This  condition  is  called  neuralgic  dysmenorrhoea. 

It  depends  upon  a  general  state  of  the  system,  which  is  supposed 
by  some  to  be  rheumatic  and  by  others  purely  neuralgic.  It  would 
be  difficult  to  define  with  any  accuracy  either  of  these  conditions,  the 
rheumatic  or  the  neuralgic  diathesis,  and  yet  we  know  enough  about 
their  manifestations  to  be  able  to  detect  their  presence. 

The  character  of  the  symptoms  of  this  form  of  dysmenorrhoea  is 
determined  by  the  conditions  of  the  system. 

It  generally  occurs  in  patients  who  are  manifestly  subjects  of  one  of 
these  diatheses,  and  who  in  the  intervals  between  the  periods  experience 
neuralgic  symptoms,  or  symptoms  referable  to  rheumatism. 

These  features  of  the  cases  are  sometimes  so  marked  as  to  be  easily 
detected,  while  at  other  times  they  are  not  well  defined.  Whether 
there  is  some  permanent  morbid  condition  of  the  nervous  apparatus 
of  the  pelvic  organs  that  is  perpetuated  from  month  to  month,  and 
thus  constitutes  the  disease,  or  whether  in  neuralgic  patients  the  vas- 
cular and  nervous  disturbance  of  the  menstrual  period  is  sufficient  to 
excite  and  localize  the  morbific  energies  of  this  diathesis,  we  do  not 
know.  I  have  been  in  the  habit  of  teaching  the  latter.  The  paroxysm 
of  suffering  is  more  irregular  with  reference  to  the  commencement  of 
the  flow  than  in  any  other  form  of  dysmenorrhoea.  More  frequently 
than  otherwise  the  pain  begins  one,  two,  or  even  three  days  before  the 
time  of  the  flow,  and  continues  in  a  subdued  degree  during  a  great 
part  of  the  time  of  the  flow.  It  is  sharp  and  paroxysmal,  but  not 
generally  accompanied  with  tenesmus.  The  pains  do  not  seem  to  be 
influenced  much  by  the  flow.  The  intensity  of  the  symptoms  vary 
from  slight  and  very  tolerable  pains  in  some  patients  to  the  greatest 
agony  in  others. 

This  kind  of  dysmenorrhoea  occurs  in  that  class  of  patients  of  whom 
it  is  often  said,  "They  suffer  more  than  any  one  else  from  the  same 
cause."  They  are  very  nervous  patients.  The  seat  of  the  pain  is  not 
always  the  same ;  sometimes  it  is  referred  to  the  uterus  exclusively, 
but  generally  the  pain  radiates  to  the  ovaries,  the  back,  in  the  region 
of  the  genito-spinal  centre,  and  down  the  limbs. 


DIAGNOSIS — PROGNOSIS TREATMENT.  309 

Diagnosis. 

A  physical  examination  of  the  pelvic  organs  enables  us  to  declare 
that  there  is  none  of  the  morbid  conditions  we  usually  find  in  the 
other  forms.  This,  with  the  diathetic  manifestations,  are  the  only 
means  of  arriving  at  definite  conclusions. 

Prognosis. 

This  affection,  although  it  is  obstinate  and  resists  treatment  of  almost 
every  kind,  and  is  apt  to  return  after  it  is  supposed  to  be  cured,  yet 
the  effects  of  judicious  treatment  upon  it  are  quite  marked. 

Treatment. 

Change  of  climate,  scenery,  and  modes  of  living  are  among  the  most 
promising  remedies.  I  have  known  patients  to  be  entirely  free  from 
dysmenorrhceal  paroxysms  during  a  long  tour  in  Europe,  and  others 
to  be  relieved  by  moving  from  a  northern  to  a  southern  climate. 
There  is  probably  no  better  way  to  produce  a  decidedly  salutary  and 
lasting  effect  upon  the  nervous  system  of  these  patients  than  to  revolu- 
tionize their  surroundings  by  change  of  climate.  A  summer  residence 
by  the  seaside,  the  bathing  and  exercise  connected  with  it,  will  often 
suffice  to  interrupt  the  recurrence  of  these  paroxysms  if  not  cure  the 
disease. 

If  we  cannot  remove  the  patient  from  the  circumstances  under 
which  her  disease  originated,  we  may  do  a  great  deal  to  get  rid  of  the 
diathesis  by  outdoor  exercise  on  horseback,  or  on  foot,  and  if  neither 
of  these  is  possible,  in  a  carriage. 

The  diet  should  be  regulated  with  a  view  to  an  exalted  state  of  nu- 
trition. Medicines  may  also  be  made  to  exercise  a  powerful  influence 
upon  the  diathetic  condition. 

In  cases  where  we  can  trace  a  rheumatic  taint  we  should  give  med- 
icines with  a  view  to  relieve  it ;  among  which  are  Dewees's  tincture  of 
guaiac.  in  drachm  doses,  three  or  four  times  a  day,  the  tincture  of  ascle- 
pias  tuberosa,  or  viburnum  prunifolium.  Ini  the  more  purely  neu- 
ralgic cases,  tonics  containing  iron,  strychnia,  quinine,  and  phosphorus 
are  serviceable.  The  phosphide  of  zinc  and  the  oxide  of  zinc  will  also 
be  found  very  useful  remedies  for  this  general  condition. 

The  manner  of  treatment  of  the  paroxysm  is  also  of  great  importance. 
As  we  can  calculate  with  some  definiteness  the  time  when  the  par- 
oxysm will  come,  we  may  anticipate  it  with  such  remedies  as  will 
produce  a  strong  impression  on  the  nervous  system. 

The  late  Dr.  M.  B.  Wright  taught  his  students  that  large  doses  of 
quinine  given  one  or  two  days  before  the  expected  paroxysm,  with  a 
view  to  having  the  patient  pass  into  it  in  a  state  of  cinchonism,  often 
mitigated  her  suffering  very  greatly,  and  sometimes  entirely  prevented 


310  1  DYSMENOEEHCEA. 

it.  If,  as  he  supposed,  many  cases  were  due  to  malarial  influences 
we  might  expect  great  good  from  this  treatment.  Arsenic  is  another 
remedy  that  will  sometimes  mitigate  the  sufifering  if  given  so  as  to 
exert  its  full  influence  at  the  time  of  the  paroxysm.  To  do  this  its 
administration  must  be  commenced  at  least  a  week  before  the  return, 
and  be  continued  from  small  to  increasing  doses  until  characteristic 
effects  appear.  In  giving  remedies  for  the  relief  of  pain  during  the 
paroxysms  we  should  have  in  mind  that  patients  afflicted  with  this 
form  of  dysmenorrhoea  are  easily  fascinated  with  the  effects  of  anodynes 
and  give  them  up  with  great  reluctance,  and  that  there  is  therefore 
great  danger  of  making  opium-eaters  of  them. 

I  could  point  out  a  number  of  patients  who  have  abused  the  pre- 
scriptions given  them  for  this  purpose  to  their  great  sorrow. 

We  should  feel  a  proper  sense  of  responsibilty  in  these  cases,  use 
anodynes  as  sparingly  as  possible,  and  place  them  beyond  the  reach 
of  the  patient  when  the  urgency  of  the  symj)toms  has  passed.  Chloral, 
chloroform,  and  morphia  are  the  anodynes  upon  which  we  will  be 
obliged  to  rely  in  the  extreme  agony  of  a  paroxysm. 

The  Inflammatory  Form  of  Dysmenorrhoea. 

In  this  variety  of  dysmenorrhoea  the  condition  giving  rise  to  the 
paroxysm  is  inflammation  in  some  of  the  pelvic  organs,  generally  the 
uterus,  the  ovaries,  or  both.  Whether  there  is  a  pure  ovarian  dys- 
menorrhoea of  this  nature  or  not,  I  am  not  prepared  to  positively 
assert,  but  I  think  it  very  probable  that  there  is.  In  most  cases  of 
inflammatory  dysmenorrhoea,  however,  I  believe  the  morbid  condition 
exists  in  both  the  ovaries  and  uterus.  In  exceptional  instances  the 
inflammation  may  be  located  in  the  cellular  tissue,  and  perhaps  in 
other  pelvic  structures. 

Symptoms. 

Patients  laboring  under  this  form  of  the  afl'ection  are  generally  the 
subjects  of  intramenstrual  symptoms  of  sufficient  intensity  to  mark 
the  nature  of  the  causing  conditions.  They  are  the  usual  symptoms 
of  uterine  or  ovarian  disease.  It  is  in  this  form  that  intramenstrual 
paroxysms  occur  midway  between  the  menstrual  periods.  These  in- 
tramenstrual paroxysms  are  sometimes  very  severe,  but  probably  are 
not  so  intense  as  those  occurring  during  the  periods. 

The  paroxysms  usually  commence  some  hours,  and,  occasionally,  a 
day  or  two  before  the  flow,  and  partially  or  completely  cease  as  soon 
as  the  flow  is  established  and  becomes  free.  The  pain  is  generally  of 
a  somewhat  steady  aching  character,  not  so  intense,  but  more  contin- 
uous than  the  neuralgic  form.  The  paroxysm  is  usually  attended 
with  febrile  phenomena.  Sometimes  there  is  a  sharp  attack  of  fever, 
preceded  by  chilliness,  and  accompanied  with  furred  tongue,  headache, 


THE   INFLAMMATORY    FORM    OF    D YSMENORRHCEA .  311 

and  pain  in  the  limbs.  The  pain  is  not  always  confined  to  the  pelvis, 
but  radiates  upward  and  downward.  The  paroxysm  is  usually 
accounted  for  by  supposing  that  the  pain  due  to  the  existing  inflam- 
mation is  very  much  aggravated  by  the  hypersemia  and  hypersesthesia 
attendant  upon  the  occurrence  of  menstruation.  However  this  may 
be,  they  are  distinguished  by  this  similarity  to  the  pains  of  inflamma- 
tion. 

Diagnosis. 

A  thorough  physical  examination,  for  which  I  will  refer  the  reader 
to  the  Diagnosis  of  Uterine  Disease,  will  enable  us  to  discover  the  lo- 
cality, character,  and  grade  of  the  morbid  process. 

Prognosis. 

The  prognosis  of  this  form  of  dysmenorrhoea  I  believe  to  be  more 
favorable  than  any  of  the  others,  because  more  amenable  to  treatment. 
It  does  not  cause  that  intensity  of  suffering  which  we  witness  in  some 
of  the  other  varieties. 

It  may  not  be  irrelevant  to  state  here  that  while  we  do  meet  with 
pure  examples  of  neuralgic  and  inflammatory  dysmenorrhoea  there  is 
often  an  obvious  neuralgic  element  in  the  inflammatory  form — a  com- 
plication of  the  two  varieties.  Sometimes  one  of  these  morbid  condi- 
tions predominates,  and  sometimes  the  other. 

Treatment. 

For  the  special  treatment  of  the  inflammation  as  the  controlling 
element  in  this  affection  I  must  refer  the  reader  to  the  methods  of 
treatment  elsewhere  given.  The  progress  of  the  cure  of  that  element 
will  be  marked  by  the  subsidence  of  the  intensit}^  of  the  paroxysms^ 
until  they  fail  to  return. 

In  this  form  we  may  often  anticipate  the  paroxysms,  and  allay  them-, 
by  appropriate  treatment.  The  patient  should  be  directed  to  take  her 
bed  before  it  comes  on,  and  remain  quiet  until  the  paroxysm  is  over. 
Particular  attention  should  be  directed  to  her  bowels,  and  it  will  often 
be  best  to  give  her  a  small  dose  of  a  mercurial — two  or  three  grains 
of  calomel,  and  follow  it  in  seven  or  eight  hours  by  a  saline  cathartic. 
After  this  diaphoresis  should  be  encouraged  by  the  acetate  of  potash, 
and,  as  the  pains  begin,  Dover's  powder.  The  anticipatory  local  treat- 
ment consists  in  bloodletting  by  leeches  or  scarification  the  day  before 
the  expected  paroxysm.  Hot-water  injections,  continued  through  the 
attack  as  often  as  three  or  four  times  in  twenty-four  hours,,  hot  fomen- 
tations over  the  hypogastrium,  and  tepid  sitz-baths.  These  will  often 
do  away  with  the  necessity  of  using  anodynes.  When  the  pain  is  not 
relieved  by  these  measures  anodynes  in  sufficient  quantities- to  miti- 
gate it  are  permissible. 


3 1 2  DYSMENOREHCEA. 

Membranous  Dysmenorrhosa. 

The  particular  feature  of  this  form  of  dysmenorrhoea  is  the  discharge 
of  a  membranous  cast  of  the  cavity  of  the  uterus.  Sometimes  the 
membrane  comes  away  without  losing  its  shape  or  integrity ;  very 
much  more  frequently  it  is  discharged  in  a  broken  condition,  and  ap- 
pears in  shreds  or  large  pieces,  representing  in  shape  and  size  the 
anterior  or  posterior  wall  of  the  cavity  of  the  uterus. 

"  The  microscope  shows  that  the  discharges  at  times  consist  simply 
of  fibrinous  clots,  which  are  with  difficulty  passed  through  the  os 
uteri,  when  it  is  very  small,  as  is  frequently  the  case  in  females  who 
have  never  borne  children  ;  at  other  times  the  fibrin  is  in  a  fibrillated 
state,  inclosing  in  its  reticulum  numerous  lymph  and  epithelial  cells. 
In  other  cases  there  are  found  irregular  shreds,  containing  capillary 
vessels  with  embryonic  walls,  in  the  midst  of  connective  tissue,  infil- 
trated with  lymph-cells.  There  are  also  frequently  seen  fragments  of 
uterine  glands.  This  is  a  genuine  discharge  of  exfoliated  mucous 
membrane.  The  mucous  membrane  may  be  expelled  entire ;  this, 
however,  is  not  of  frequent  occurrence."* 

Numerous  theories  have  been  propagated  to  explain  the  formation 
of  this  membrane.  It  would  seem  that  the  ideas  prevailing  with 
reference  to  the  formation  of  the  deciduous  membrane  have  influ- 
enced the  profession  in  their  opinions  as  to  the  conditions  giving  rise 
to  this  membranous  formation. 

In  the  theory  adopted  by  Dewees,  Montgomery,  and  others,  that  it 
is  a  layer  of  plastic  lymph  spread  upon  the  uterine  wall,  we  see  some- 
thing of  the  Hunterian  explanation  of  the  formation  of  the  decidua. 
In  another  theory,  advanced  by  Oldham  and  others,  we  see  the  results 
of  the  researches  of  Coste,  who  considers  the  decidua  nothing  more 
than  the  mucous  membrane  of  the  uterus,  changed  by  impregnation. 
According  to  this  theory  it  is  the  menstrual  decidua  which  does  not 
undergo  disintegation  as  completely  as  in  health ;  in  other  words  the 
membrane  is  the  result  of  hypernidation.  In  the  natural  condition  of 
the  uterus  the  mucous  membrane  undergoes  changes  that  render  it 
suitable  to  become  the  nidus  for  and  to  embrace  and  fix  the  ovum  in 
its  development.  When  conception  does  not  take  place  the  disintegra- 
tion of  the  membrane  and  the  flow  are  contemporaneous.  If  the 
membrane  is  overdeveloped  by  reason  of  a  preternatural  amount  of 
connective  tissue,  then  the  membrane  retains  its  integrity  to  a  certain 
degree,  and  instead  of  flowing  out  as  debris  it  is  expelled  as  a  whole 
or  in  large  shreds. 

I  believe  with  Scanzoni  that  the  uterus  in  which  the  formation  of 
this  membrane  occurs  is  in  a  state  of  hypersemia.     Sometimes  this 

■*  Cornil  and  Eanvier's  Pathological  Histology,  translated  by  Shakespeare  and  Simes, 
p.  68ot. 


MEMBRANOUS    DYSMENOREHCEA .  313 

hypersemia  is  trophic,  and  then  the  membrane  will  contain  capillary- 
bloodvessels  and  utricular  glands,  while  in  others  it  is  inflammatory, 
and  the  discharge  will  contain  fibrinous  clots  and  false  or  fibrinous 
membrane,  inclosing  in  its  reticulum  lymph  and  epithelial  cells. 

This  view  of  the  subject  will  enable  us  to  explain  the  microscopic 
appearances  noticed  in  different  cases.  Clinical  observation  will  also 
sustain  the  position  that  inflammation  is  the  main  factor  in  a  portion 
of  these  cases  at  least. 

In  the  cases  in  Avhich  there  is  trophic  hypersemia,  the  initial  or 
actuating  condition  is  probably  nervous,  and  the  influence  reflected 
through  the  ovaries,  as  in  the  production  of  normal  menstrual  conges- 
tion or  the  hypersemia  of  pregnancy. 

Symptoms. 

The  paroxysm  is  sometimes  ushered  in  by  nausea,  vomiting,  rapid 
pulse,  furred  tongue,  headache,  and  increased  temperature,  and  in 
many  respects  resembles  inflammatory  dysmenorrhoea ;  at  other  times 
there  are  no  febrile  symptoms ;  but  in  most  cases  of  membranous 
dysmenorrhoea  the  stomach  sympathizes  with  the  pelvic  trouble. 

The  pains  usually  begin  after  the  commencement  of  the  flow  and 
continue  until  the  membrane  passes.  They  are  at  first  sharp,  and 
dart  from  the  pelvis  in  every  direction,  afterward  cramping,  and 
finally  tenesmic  or  expulsive.  The  pains  have  for  their  object  the 
separation  and  expulsion  of  the  membrane,  and  subside  as  soon  as 
'this  is  accomplished. 

The  more  complete  the  formation  of  the  membrane,  the  more  urgent 
and  painful  the  efforts  to  get  rid  of  it.  The  most  distressing  part  of 
the  suffering  depends  upon  the  eff'ort  to  overcome  the  resistance  of  the 
OS  uteri  to  the  evacuation  of  the  membrane. 

Without  this  resistance  it  is  uncertain  whether  there  would  be  much 
pain,  as  I  have  known  two  cases  in  which  the  membrane  was  repeat- 
edly evacuated  without  pain.  In  both  cases  the  internal  os  uteri  was 
patulous.    I  have  never  seen  the  membrane  expelled  by  parous  women. 

Diagnosis. 

This  depends  upon  the  discovery  of  the  membrane  either  in  pieces 
or  as  a  whole.  While  my  observation  has  not  been  sufficiently  ex- 
tensive to  enable  me  to  establish  a  rule  even  for  my  own  guidance,  I 
believe  it  will  be  found  that  in  cases  attended  with  febrile  symptoms 
the  membrane  will  be  of  a  plasmic  character  wholly,  and  that  in 
those  unattended  by  these  symptoms  the  membrane  will  partake  njore 
of  the  deciduous  character. 

The  prognosis  of  membranous  dysmenorrhoea  is  not  very  encourag- 
ing, as  it  is  very  difficult  to  overcome  the  disposition  to  the  formation 
of  the  membrane. 


314  DYSMENORRHCEA. 


Treatment. 


The  paroxysm  of  membranous  dysmenorrhoea,  especially  the  more 
febrile  form,  should  be  treated  with  a  view  to  removing  the  obstruc- 
tion. The  cervix  should  be  dilated  by  Hunter's  or  some  other  dilator 
as  soon  as  the  pains  become  severe  and  expulsive  in  character :  this 
will  generally  very  materially  shorten  the  duration,  as  it  facilitates  the 
discharge  of  the  membrane.  In  connection  with  the  dilation,  or  with- 
out, an  efficient  dose  of  ergot  will  sometimes  aid  the  process  of  expul- 
sion very  materially. 

Sometimes  we  may  prevent  or  mitigate  the  severity  of  a  paroxysm 
by  using  a  fasciculus  of  slippery-elm  tents  a  day  or  two  before  it 
occurs,  especially  in  the  febrile  form. 

If  the  paroxysm  is  attended  with  vomiting  and  fever,  we  should 
anticipate  it  by  giving  a  cathartic  the  day  before  its  occurrence  and 
administer  large  doses  of  quinine. 

The  administration  of  ergot  between  the  paroxysms  in  the  trophic 
variety  will  aid  very  materially  in  overcoming  the  hypersemic  condi- 
tion of  the  uterus,  and  produce  a  favorable  influence  upon  the  nerve- 
centres  that  preside  over  the  process  of  ovulation.  Mercurial  and 
iodine  alteratives  should  take  its  place  in  the  inflammatory  variety. 
The  ammoniated  tincture  of  guaiac.  may  be  given  with  great  propriety 
when  a  rheumatic  diathesis  is  suspected.  The  local  treatment  of  the 
two  is  very  nearly  the  same,  viz.,  dilatation  and  applications  to  the 
mucous  membrane  of  the  cavity  of  the  body  of  the  uterus,  as  in  cases 
of  chronic  inflammation  and  congestion  of  that  organ. 

Obstructive  Dysmenorrhoea. 

The  clinical  study  of  dysmenorrhoea  will  force  upon  the  observer 
the  conviction  that,  in  the  majority  of  cases,  this  symptom  is  the  re- 
sult of  uterine  contractions,  and  that  the  contractions  are  efforts  made 
by  the  uterus  to  expel  its  contents. 

As  I  have  already  shown,  this  is  the  case  in  the  membranous  variety, 
the  real  cause  of  the  expulsive  pains  being  obstruction,  not  because 
there  is  contraction  of  the  os  uteri  or  cervical  canal,  but  because  the 
substance  expelled  required  more  room  for  its  passage  than  was 
afforded  by  the  os  of  normal  size. 

In  the  inflammatory  variety  the  same  kind  of  pains  are  often  no- 
ticed. Doubtless  the  cause  of  the  expulsive  efforts  in  this  variety  is 
the  temporary  stenosis  of  the  internal  os  uteri,  caused  by  the  tumefac- 
tion of  the  mucous  membrane  at  that  point  at  the  time  of  the  men- 
strual congestion.  This  explanation  presupposes  endometritis  with 
the  greatest  intensity  of  the  inflammation  at  that  point.  Between  the 
menstrual  periods  the  tumefaction  subsides,  and  the  os  presents  no 
evidence  of  stenosis.     This  is  one  form  of  temporary  stenosis  causing 


OBSTRUCTIVE   DYSMENOERHCEA.  315 

dysmenorrhoea.  Another  is  spasm  of  the  circular  fibres  surrounding 
the  internal  os  uteri  at  the  time  of  menstruation. 

We  are  prepared  to  understand  how  this  may  take  place  in  patients 
of  irritable  fibre,  when  we  remember  the  hypersBsthesia  that  accom- 
panies chronic  inflammation  of  the  uterus  and  the  congestion  preced- 
ing the  eruption  of  the  menstrual  discharge. 

I  have  no  doubt  that  the  cause  of  temporary  stenosis,  even  in  the 
inflammatory  form,  is  often  spasmodic  closure,  as  blepharospasm  is 
caused  by  conjunctival  inflammation. 

I  think  this  spasmodic  action  is  much  more  likely  to  occur  in  the 
inflammatory  than  in  the  neuralgic  variety.  There  is  one  condition 
in  which  the  expulsive  pains  of  dysmenorrhoea  manifest  themselves 
with  great  severity  where  no  stenosis  exists.  When  there  is  a  great 
degree  of  retroversion  or  retroflexion  the  cavity  of  the  body  is  lower 
than  the  internal  os  uteri. 

In  such  cases  the  extravasated  blood,  instead  of  flowing  toward  the 
mouth  of  the  uterus,  gravitates  into  the  fundal  portion  of  the  cavity 
and  there  accumulates  until  its  presence  excites  uterine  contractions. 

Fig.  191. 


&^;!!!M. 


if 


Strong  Retroflexion  favoring  Gravitation  to  tlie  Fundus, 

It  would  seem  from  these  considerations  that  much  of  the  suff'ering 
connected  with  retroflexion,  and  even  anteflexion,  with  or  without 
stenosis,  is  fairly  attributable  to  the  gravitation  of  the  blood  into  in- 
stead of  out  of  the  uterus. 

I  would  call  attention  to  the  figure  of  retroflexion,  here  introduced 
to  demonstrate  this  proposition  ;  Would  it  be  possible,  even  if  there 
was  no  stenosis,  for  the  blood  to  flow  out  of  a  uterus  in  the  position 
there  represented  ?  And  would  not  the  accumulation  of  the  blood  in 
the  dependent  cavity,  and  perhaps  coagulating  there,  as  certainly  pro- 
duce eflbrts  at  expulsion  as  any  other  foreign  body  ?  Since  my  atten- 
tion has  been  directed  especially  to  this  item,  in  the  pathology  of  dys- 
menorrhoea, I  have  been  convinced  that  too  much  importance  has  been 
attached  to  simple  stenosis. 


316  DYSMENORRHCEA. 

Nearly  all  cases  of  obstructive  dysmenorrhoea  are  associated  with 
displacement  or  fiexional  deformity  of  the  uterus.  When  gravity  fa- 
vors the  outflow  of  the  menstrual  blood  it  requires  only  a  very  small 
passage  through  which  to  escape.  I  have  repeatedly  examined  patients, 
in  whom  the  external  os  uteri  was  not  larger  than  a  pinhole,  whose 
menstrual  flow  was  easy  and  copious.  While  thus  expressing  myself 
with  reference  to  the  importance  of  malposition  and  fiexional  deform- 
ity of  the  uterus  as  offering  a  sufficient  impediment  to  the  discharge 
of  the  blood  to  induce  the  most  distressing  form  of  dysmenorrhoea,  I 
would  not  ignore  stenosis  as  one  of  the  causes  of  it. 

Any  cause  that  will  give  rise  to  retention  of  the  menstrual  flow  will 
cause  uterine  contractions  and  pain.  A  typical  case,  in  which  dys- 
menorrhoeal  symptoms  from  forcible  retention  of  the  menstrual  fluid 
are  manifested,  is  congenital  occlusion  of  some  portion  of  the  genital 
canal.  If  the  obstruction  is  at  the  orifice  of  the  vagina,  the  pains  will 
not  be  of  this  character  until  the  vagina  is  filled  and  a  portion  of  the 
blood  is  retained  in  the  uterus  ;  but  if  the  occlusion  is  at  the  uterus, 
the  symptoms  will  begin  with  the  first  menstrual  effort.  To  witness 
a  case  of  this  kind  will  convince  the  observer  that  obstruction  to  the 
flow  will  give  rise  to  dysmenorrhoeal  symptoms.  If  there  is  a  great 
degree  of  stenosis  in  a  part  of  the  genital  canal  symptoms  of  a  similar 
character  will  occur. 

Symptoms. 

The  main  symptom  of  obstructive  or  retentive  dysmenorrhoea  is  ex- 
cruciating pain  of  an  expulsive  character.  The  pains  are  compared 
to  colic,  and  the  term  uterine  colic  is  quite  appropriate. 

They  generally  come  on  before  the  commencement  of  the  flow,  and 
continue  until  the  discharge  is  well  established,  when  they  gradually 
subside,  and  the  flow  continues  from  that  time  on  without  pain.  In 
many  instances  the  great  congestion  accompanying  the  effort  at  dis- 
charge, causing  a  sort  of  erection  of  the  uterus,  not  only  overcomes 
the  stenosis,  but  it  temporarily,  to  a  great  extent,  corrects  the  position 
or  deformity ;  without  this  correction  the  relief  would  not  be  complete. 
If  the  attendant  will  take  the  trouble  to  examine  patients  carefully 
during  the  flow — which  by  the  way  is  very  seldom  done — he  can  easily 
convince  himself  of  the  truth  of  this  statement. 

Diagnosis. 

The  diagnosis  may  be  established  by  physical  examination.  Ob- 
struction of  the  vaginal  orifice  by  the  hymen,  morbid  adhesions,  or 
congenital  deformity  may  be  detected  by  occular,  digital,  and  instru- 
mental examination  with  the  sound  during  the  presence  of  the  symp- 
toms. Malposition  or  flexions  will  be  detected  by  physical  examina- 
tion. 


OBSTRUCTIVE    DYSMENOERHCEA.  317 

Prognosis. 

Like  the  other  forms  of  clysmenorrhoea,  the  obstructive  variety  is 
apt  to  be  very  obstinate  and  difficult  to  manage  satisfactorily ;  but  as 
the  corrective  treatment  is  almost  wholly  mechanical  or  surgical,  we 
may  hope  for  good  results. 

Treatment. 

In  cases  where  there  is  retroflexion  with  dependent  fundus,  the  first 
and  most  important  corrective  measure  is  to  elevate  the  organ  so  that 
the  blood  will  flow  into  the  cervix,  and  thus  escape  from  the  os  uteri. 

This  may  be  done  before  or  at  the  time  of  the  paroxysm.  If  we  see 
the  patient  for  the  first  time  during  a  paroxysm,  we  should  place  her 
in  the  knee-chest  position,  and  lift  the  fundus  uteri  up  with  one  finger. 


Eetroflexed  Uterus  with  the  Fundus  raised  by  a  Pessary. 

By  this  means  we  straighten  out  the  cervix,  and  thus  dilate  the  con- 
tractions and  give  the  blood  an  inclined  plane  over  which  to  flow  and 
escape. 

This  I  am  assured  from  repeated  observation  will  often  relieve  a 
paroxysm.  If  this  is  not  sufficient,  with  the  patient  still  in  the  genu- 
pectoral  position,  we  should  introduce  a  sound  to  the  fundus.  In  some 
cases  elevating  the  womb,  with  or  without  the  introduction  of  the 
sound,  will  relieve  the  patient  for  a  few  hours  only ;  but  if  the  pain 
returns,  it  may  be  relieved  in  the  same  way  until  the  paroxysm  sub- 
sides. Between  the  paroxysms  a  suitable  retroversion  pessary  should 
be  worn,  and,  if  properly  placed  and  watched,  will  go  a  great  way  to- 
ward efi'ecting  a  cure. 

When  there  is  stenosis,  we  may  often  relieve  the  paroxysm  by  dilat- 
ing the  contracted  point  with  a  slippery-elm  tent. 

There  are  two  special  methods  of  relieving  stenosis,  viz. :  1.  By  in- 


318 


DYSMENOREHCEA. 


cision.     2d.  By  dilatation  or  stretching  the  parts,  with  instruments 
made  for  the  purpose,  and  tents. 

J.  Marion  Sims,  in  his  work  on  Uterine  Surgery^  propounds  the  fol- 
lowing opinions  as  to  the  causes  of  dysmenorrhoea,  and  bases  his 
treatment  on  them.     He  says  (page  142)  : 

"It  (dysmenorrhoea)  is  only  a  symjitom  of  disease,  whicli  may  be  caused  by  inflam- 
mation of  the  cervical  mucous  membrane,  retroflexion,  anteflexion,  tibroid  tumor  in 
one  wall  of  the  uterus  or  the  other,  contraction  of  the  os  externum,  flexures  of  the 
canal  of  the  cervix,  either  acute  or  greatly  curved,  either  at  the  os  internum,  at  the 
insertion  of  the  vagina,  or  extending  throughout  the  whole  lengtli  of  the  canal,  all  of 
which  are  but  so  many  mechanical  causes  of  obstruction  which  must  be  recognized 
and  remedied  if  we  expect  to  cure  the  dysmenorrhoea." 


The  following  table  is  on  page  132 : 


Of  100  cases  of  painful  menstruation. 


Of  29  cases  of  excessively  painful  menstruation, 


OS  was  normal  in  but 

6 

OS  was  contracted  in 

90 

-    cervix  was  flexed  in 

61 

congested  in     .     .     . 

7 

there  were  polypi  in 

2 

OS  was  normal  in 

0 

OS  was  contracted  in 

26 

-    cervix  was  flexed  in 

23 

had  polypi  in       .     . 

2 

was  congested  in  .     . 

1 

This  tabular  testimony  of  129  cases  is  a  strong  argument  in  favor  of 
Dr.  Sims's  theory,  that  dysmenorrhoea  is  almost  always  caused  by 
obstruction. 

As  I  have  given  the  opinion  of  Dr.  Sims  as  to  the  causes  of  dysmen- 
orrhoea, I  cannot  complete  this  article  without  giving  the  reader  an 
idea  of  the  mode  of  treatment  found  most  successful  by  him,  viz.,  that 
of  dilating  and  straightening  the  canal  of  the  cervix.  He  exposes  the 
mouth  of  the  uterus  by  placing  the  patient  in  the  same  position,  and 
using  the  same  instrument  as  for  vesico-vaginal  fistula.  With  a 
tenaculum  he  seizes  and  firmly  holds  the  cervix,  and  draws  it  into  the 
most  convenient  position.  If  the  cervix  is  not  flexed  but  merely 
narrow,  he  introduces  one  blade  of  the  scissors  into  the  canal  of  the 
cervix  far  enough  to  divide  it  on  one  side  up  to  the  junction  with  the 
vagina,  and  then  closes  them.  The  other  side  of  the  cervix  is  divided 
to  the  same  extent  in  like  manner,  then,  by  means  of  the  knife  repre- 
sented in  figure,  he  divides  the  cervix  up  as  high  as  the  internal  os. 

If  the  cervix  is  flexed,  the  lip  of  the  uterus  on  the  convex  side  is 
divided  to  the  same  height,  and  then  the  cervix  opened  with  the  knife. 
In  this  way  the  cervical  canal  is  rendered  rectilinear. 

This  is  represented  by  Fig.  195,  taken  from  page  169  of  Dr.  Sims's 
work  on  Uterine  Surgery.     It  shows  the  posterior  lip  already  divided 


OBSTRUCTIVE  DYSMENOERHCEA. 


319 


by  the  scissors,  the  tenaculum  fastened  into  the  anterior  lip,  and  the 
knife  being  inserted  as  high  as  necessary  : 

"  The  representation  in  the  cnt  is  taken  from  the  perfected  instrument  made  by 
Wade  &  Ford,  of  New  York  City.  To  their  ingenuity  is  due  the  application  of  the 
principle.  The  representation  is  half  the  size  of  the  instrument,  but  the  blade  at  full 
size  is  out  of  proportion,  as  it  should  be  represented  both  longer  and  narrower." 

Fig.  193. 


Fig.  193  represents  the  Operation  for  Dividing  the  Straight  Cervix  when  too  narrow.  The  dark 
part  is  the  portion  cut.  On  one  side  the  knife  is  shown  in  the  act  of  dividing  the  tissues.  This 
is  Dr.  Sims's  plan. 

After  having  thus  completed  the  operation  Dr.  Sims  places  in  the 
wound  of  the  lip  of  the  cervix  some  cotton  saturated  with  glycerin, 

Fig.  194. 


Emmet's  Knife  for  Dividing  the  Cervix.    From  a  cut  in  the  June  number,  1864,  New 
York  Journal  of  Medicine. 

and  then  proceeds  to  fill  the  vagina  with   cotton  to  guard  against 
hemorrhage,  which  he  regards  as  always  imminent.     If  there  be  but 


320 


D  YSMENORRHCE  A . 


slight  bleeding,  it  is  not  necessary  to  use  more  cotton  than  will  keep 
the  dressing  in  place.  The  patient  should  keep  the  recumbent  post- 
ure for  several  days.  The  cotton  in  the  vagina  may  be  removed  in 
twenty-four  hours  after  the  operation ;  that  in  the  wound  remains 
from  two  to  three  days.     Dr.  Emmet  recommends  that  the  sound  be 


Fig.  195. 


passed  through  the  cervix  every  other  day  until  the  discharge  ceases 
to  prevent  the  parts  from  adhering.  The  sound  need  not  be  used  for 
this  purpose  until  the  tampon  is  dispensed  with. 

The  following  are  the  conclusions  in  practice  of  the  late  Dr.  E.  R. 
Peaslee  :* 

"  From  the  preceding  facts  I  deduce  the  following  conclusions : 

"  I.  The  deep  incision  of  the  cervix  throughout,  the  complete  bilateral  discission  of 
the  vaginal  portion  with  deep  incision  above,  are  alike  frequently  attended  by  certain 
immediate  dangers,  and  not  seldom  productive  of  certain  serious  remote  consequences, 
viz.,  profuse  and  sometimes  fatal  hemorrhage,  pelvic  cellulitis,  septic  peritonitis 
(usually  fatal),  sterility,  if  not  previously  existing,  and  a  tendency  to  miscarriage. 

"  II.  Those  risks  and  efTects  are  all  due  to  the  extensive  division  of  the  walls  of  the 
cervix,  and  to  the  consequent  enlargement  of  the  cervical  canal ;  and  the  sole  com- 
pensation for  all  of  them  which  can  be  calculated  upon  is  the  relief,  and  very  often 
the  cure,  of  stenotic  dysmenorrhoea. 

"  It  therefore  becomes  a  question  of  very  great  practical  importance  whether  the 
amount  of  cutting  may  not  be  so  far  diminished  as  to  avoid  all  these  risks,  and  at  the 
same  time  be  sufiBcient  for  the  cure  of  stenotic  sterility  and  dysmenoi-rhcea.  But  another 
inquiry  antecedent  to  this  is,  how  large  a  calibre  of  the  cervical  canal  is  actually  re- 
quired for  the  relief  of  these  two  conditions;  and  a  reply  sufficiently  definite  for  all 
practical  purposes  is  not  so  difficult  as  might  appear. 

"  In  the  imparous  woman,  the  narrowest  point  of  the  cervical  canal,  viz.,  the  internal 
OS,  is,  when  opened  by  the  passage  of  the  menstrual  fluid,  an  ellipse,  whose  conjugate 
and  transverse  diameters  average  respectively  one-sixth  and  one-eighth  of  an  inch  ; 


*  A  paper  read  before  the  New  York  Academy  of  Medicine,  1876. 


peaslee's  method.  321 

its  area  corresponding  very  nearly*  with  that  of  a  circle  one-seventh  of  an  inch  in 
diameter.  The  external  os,  also  elliptical  when  moderately  dilated,  has  diameters 
averaging  one-fourth  and  one-sixth  of  an  inch.  It  thus  has  an  area  exactly  twice  that 
of  the  internal  os,  and  equalling  that  of  a  circle  one-fifth  inch  in  diameter.f  The 
larger  size  of  the  external  os  doubtless  has  a  special  reference  to  conception,  and  favors 
the  entrance  of  the  spermatic  iiuid  into  the  cervical  canal.  It  has  no  special  influence 
against  dysmenorrhcea,  since  the  menstrual  fluid,  after  having  passed  through  the  in- 
ternal os  into  the  cervical  canal,  would  pass  just  as  easily  from  the  latter  through  an 
opening  of  the  same  dimensions  into  the  vagina.  Hence,  we  not  very  seldom  see  im- 
parous  women  with  tlie  external  OS  no  larger  than  a  'pin-hole,'  and  who,  neverthe- 
less, do  not  suffer  from  dysmenorrhcea,  though,  as  a  rule,  they  are  sterile.  But  if  the 
lining  membrane  of  the  canal  becomes  thicker  from  congestion,  or  some  other  cause 
such  patients  suffer  at  once  from  stenosis  at  the  external  os. 

"  In  the  pa)-ozts  woman,  the  size  of  the  external  os  varies  within  quite  extensive 
limits,  since  it  is  exposed  to  so  many  of  the  accidents  of  parturition,  while  the  internal 
OS  is  more  nearly  uniform. 

"I  have  deemed  it  desirable  to  ascertain  the  lowest  average  diameter  of  the  two  ora 
uteri  in  parous  women,  who  are  neither  sterile  nor  have  dysmenorrhcea,  as  a  rational 
standard  for  determining  the  extent  of  incision  actually  required  for  the  removal  of 
these  two  conditions  when  stenotic.  And,  after  a  good  deal  of  observation  in  this 
direction,  I  find  that  the  inner  os  presents  nearly  twice  the  area  of  that  of  the  im- 
parous  woman ;  in  the  majority  of  cases  admitting  a  sound  one-fifth  of  an  inch  in 
diameter,  though,  in  a  large  minority,  one  from  one-fifth  to  one-sixth  of  an  inch  only 
can  be  easily  passed.  I  therefore  regard  a  diameter  of  one-fifth  of  an  inch  as  ample 
for  the  removal  of  sterility  and  dysmenorrhcea.  I  find  the  external  os  admits  a  dilator 
one  fifth  of  an  inch  in  diameter  and  upward — in  some  cases  as  high  as  one-fourth  or 
even  three-tenths  of  an  inch — but,  as  a  rulfe,  I  think  one-fourth  of  an  inch  sufficient 
-for  the  purpose.  It  is  of  course  to  be  understood  that  no  nan-owing  of  the  canal  exists 
between  the  two  ora.  Since,  however,  there  may  be  some  degree  of  stenosis  for  the 
menstrual  fluid,  while  not  for  the  sound,  it  is  sometimes  judicious  (and  especially  if 
congestion  of  the  cervical  lining  membrane  coexists)  to  increase  the  dimensions  just 
named,  by  the  use  of  a  dilator  of  the  next  larger  size.  1  do  not  assert  that  the  preced- 
ing dimensions  are  always  required  in  the  treatment  of  stenotic  sterility  and  dysmen- 
orrhcea, for  they  are  not,  nor  that  they  are  never  to  be  exceeded,  but  that  in  almost  all 
cases  they  will  be  found  sufficient. 

"Should  this  precise  specification  of  dimensions  seem  too  minute  for  practical  pur- 
poses, we  must  remember  that  dimension  cannot  here  have  a  less  important  relation 
to  function  than  elsewhere;  and  that  enlarging  the  internal  os  to  the  diameter  of  half 
an  inch,  as  is  often  done  by  the  deep  incision,  is,  as  lias  been  seen,  like  permanently  di- 
lating the  urethra  (if  it  could  be  done)  to  the  size  of  the  small  intestine.  And  the  im- 
portance of  making  an  incision  of  the  internal  os,  with  a  precise  intention  and  a  pre- 
cise knowledge  of  the  mode  of  accomplishing  what  is  intended,  may  be  understood 
when  I  state  that  if  the  circle  representing  its  area  in  the  imparous  woman  be  increased 
equivalently  to  surrounding  it  by  a  ring  only  one  thirty-fifth  of  an  inch  wide,  its  area 
is  increased  as  forty-nine  to  twenty-five,  or  almost  exactly  double.  Or,  if  an  incision 
be  made  on  each  side  of  it  to  the  extent  of  half  a  line  (one  twenty-fourth  of  an  inch), 
and  it  then  be  dilated  to  a  circle,  it  is  increased  two  and  a  half  times.  And  if  the  cut 
should  extend  one  line  to  the  right  and  the  left,  or  the  added  ring  were  one-twelfth  of 
an  inch  wide,  the  area  would  be  increased  more  than  four  times  and  a  half.     This  last 

*  The  circle  is  smaller  than  the  ellipse,  in  the  proportion  of  144  to  147. 
f  Circle  to  ellipse  as  72  to  75. 

21 


322  DYSMENOEEHCEA. 

increase  is  far  more,  in  my  experience,  than  is  ever  required  in  stenotic  sterility  and 
dysmenorrhcea. 

Superficial  Trachelotomy — My  own  Operation. 

"III.  Desiring  to  restrict  the  operation  of  trachelotomy  in  the  treatment  of  stenotic 
sterility  and  dysmenorrhcea  within  the  limits  actually  required,  I,  some  ten  years  ago, 
devised  and  brought  before  the  Xew  York  Obstetrical  Society*  a  series  of  five  steel 
cervical  dilators,  to  be  used  instead  of  incision,  where  the  stenosis  is  slight  and  the 
cervix  is  normally  soft  and  pliable.  These,  in  shape  and  size,  have  a  precise  refer- 
ence to  the  dimensions  of  the  cervical  canal,  and  especially  of  the  two  era  uteri,  as 
already  specified  ;  and  each  is  guarded  by  a  bulb,  so  as  to  project  through  the  internal 
OS  into  the  uterine  cavity  only  about  one-quarter  of  an  inch. 

"  But  finding  that  almost  all  cases  of  stenosis  of  the  cervical  canal  are  relieved  more 
promptly,  more  permanently,  and  also  with  less  pain,  by  incision,  or  this  together  with 
dilatation,  than  by  any  form  of  dilatation  alone  ;  I  next  endeavored  to  restrict  the  extent 
of  the  incision  within  the  absolutely  necessary  limits,  having  determined  them  ap- 
proximately by  the  preceding  facts  and  calculations.  To  this  end  I  devised  a  new 
method,  and  an  instrument  for  executing  it,  which  I  also  laid  before  the  New  York 
Obstetrical  Societj'^  about  eight  years  since ;  but  the  former  was  so  simple,  bloodless, 
and  unpretending,  in  comparison  with  the  procedures  of  Simpson  and  Sims,  that  it 
excited  but  little  interest.  Meanwhile,  however,  it  has  been  suSiciently  tested,  I 
think,  by  myself  and  my  pupils  in  different  parts  of  tiie  country,  to  entitle  it  to  a  more 
general  notice. 

"  vSince  the  superficial  incision,  as  suggested  by  myself,  has  for  its  direct  object 
merely  the  removal  of  stenosis  of  the  cervical  canal,  and  is  therefore  proposed  for  the 
treatment  of  stenotic  dysmenorrhcea  and  sterility  only,  it  is  previously  to  be  decided 
whether  stenosis  actually  exists.  And  the  following  propositions  will  aid  in  settling 
this  question,  it  being  understood  that  the  exploration  is  to  be  made  at  least  four  days 
after,  and  at  least  three  days  before,  the  catamenial  flow. 

A.  Respecting  Stenosis  of  the  Internal  Os. 

"1.  If  a  sound  one-fifth  of  an  inch  in  diameter  passes  easily  through  the  cervical 
canal,  there  is  no  stenosis  at  the  internal  os,  and  no  incision  is  there  required.  Tiiis 
is  the  size,  therefore,  of  my  large  sound. 

"  2.  If  a  sound  one-sixth  of  an  inch  in  diameter  be  easily  passed,  as  above,  there  is 
no  absolute,  though  there  may  be  relative  stenosis  of  the  internal  os  ;  i.e.,  there  may 
be  stenosis  for  the  passage  of  a  fluid,  though  not  of  the  sound ;  and  an  incision  to  make 
it  one-fifth  of  an  inch  may  be  required,  but  not  unless  the  symptoms  indicate  it. 

"3.  If  the  sound  easily  passed  be  but  one-seventh  of  an  inch  in  diameter,  and  there 
are  no  symptoms  of  stenosis,  no  incision  of  the  internal  os  is  required.  This  is  the 
normal  size  in  the  imparons  woman,  and  the  average  size  of  Simpson's  sound. 

"4.  If  a  sound  but  one-eighth  of  an  inch  in  diameter  cannot  be  passed  through  the 
internal  os,  there  is  either  stenosis,  or,  what  is  very  much  more  probable,  one  of  the 
flexions.  Prove,  therefore,  that  there  is  no  flexion  in  this  and  every  case  in  which  a 
sound  of  any  size  does  not  traverse  the  internal  os  before  operating  for  stenosis.  I 
consider  an  internal  os  of  one-eighth  of  an  inch  or  less  to  be  stenotic.  Ciirobak's 
highest  limit  for  stenosis  of  the  internal  os  is  one-tenth  of  an  inch  (two  and  a  Iialf 
millimeters). 


*  Also  described  in  the  New  York  Medical  Journal,  July,  1S70,  p.  478. 


PEASLEE  S   METHOD. 


323 


B.  Respecting  Stenosis  of  the  External  Os. 

"  5.  On  the  other  hand,  there  is  no  stenosis  of  the  external  os  if  a  sound  one-fifth  of 
an  inch  in  diameter  easily  traverses  it.  If  there  be  congestion  of  the  lining  membrane, 
however,  there  may  be  stenosis,  practically,  in  respect  to  conception ;  and  the  opera- 
tion somewhat  enlarging  it  (to  one-quarter  of  an  inch  or  more)  may  be  required. 

"  6.  If  the  external  os  will  not  easily  admit  a  sound  one-sixth  of  an  inch  in 
diameter,  there  is  probably  stenosis  in  respect  to  conception,  and  the  operation  is  re- 
quired. If  not  more  than  one-seventh  of  an  inch,  the  operation  will  also  probably  be 
required  for  dysnienorrhcea. 

"  7.  In  case  of  operation,  the  whole  cervical  canal  must  be  made  still  to  retain  the 
normal  fusiform  sliape  as  far  as  possible. 

"  I.  My  method  consists  in  incising  the  internal  os,  if  the  stenosis  exists  at  that  part, — 
and  the  externa],  if  at  the  latter, — to  such  an  extent  as  to  give  to  each  its  precise 
average  dimensions  in  the  parous  woman,  neither  more  nor  less,  and,  of  course,  also 
overcoming  any  other  point  of  stenosis  existing  anywhere  else  in  the  cervical  canal. 
In  cases  complicated  with  congestion,  however,  I  have  shown  that  a  slightly  larger 
opening  may  be  required,  and,  therefore,  that  the  limits  may  extend  beyond  one-fifth 
of  an  inch  to  nearly  a  quarter  of  an  inch  in  the  case  of  the  internal  os,  and  to  three- 
tenths  of  an  inch,  and  possibly  more,  of  the  external. 

"  I  do  not,  therefore,  incise  the  internal  or  the  external  os  to  a  given  depth  in  all 
cases,  but,  taking  them  as  I  find  them,  cut  just  enough  to  give  them  their  average 
normal  size  in  the  parous  uterus.  This  is  seldom  one-half  of  a  line  and  often  not  more 
than  one-third  of  a  line  for  the  internal  os,  and  not  more  than  a  line  for  the  external. 
But,  of  course,  there  is  far  more  variation  in  the  latter.     If  the  internal  os  admits  a 

Fig.  196. 


Dr.  Peaslee's  Metrotome,  half-size. 

sound  of  but  one-eighth  of  an  inch  in  diameter,  a  cut  on  each  side  of  nearly  half  a  line 
(but  three-eightieths  of  an  inch)  is  required  ;  and  if  but  one-tenth  of  an  inch  in 
diameter,  it  must  be  one-twentieth  of  an  inch  deep  on  each  side.  The  incisions  are  of 
precisely  the  same  depth  on  each  of  the  two  sides. 

"Since  the  lining  membrane  at  the  internal  os  is  at  most  one  twenty -fifth  of  an  inch 
thick,  it  is  seen  that  I  generally  do  not  cut  nearly  through  it.  Indeed,  when  the  os  is 
but  one-eighth  of  an  inch  wide,  I  cut  almost  through  the  membrane ;  and  when  one- 
tenth  of  an  inch,  I  divide  it  and  one-hundredtli  of  an  inch  of  the  tissue  beneath  it* 

"II.  The  m.sf/-ume?i^  devised  to  secure  this  effect  consists  of  a  flattened  tube,  con- 
taining a  blade.  The  former  is  eight  inches  long  and  seven-sixteenths  of  an  inch 
wide,  except  its  terminal  one  inch  and  three-quarters,  which  has  a  width  of  but  one- 
eighth  of  an  inch,  as  shown  in  Fig.  196.  This  portion  is  made  curved  by  some  in- 
strument makers,  which  is  not  an  improvement.  The  blade  is  of  such  a  width  as  to 
slide  accurately  within  the  tube,  having  a  nut  and  a  screw  attached  to  its  proximal 
extremity  to  gauge  the  extent  of  its  passage  into  the  cervical  canal,  and  a  blunt  point 


*  The  details  of  all  the  preceding  calculations  are  properly  omitted  here,  as  a  slight 
acquaintance  with  mathematics  will  enable  the  reader  to  verify  them. 


324  DYSMENOREHGEA. 

and  lateral  cutting  edges  for  an  inch  and  five-eighths  at  the  distal  end.  There  are  two 
blades  for  each  instrnment,  the  cutting  portion  of  one  being  a  quarter  of  an  inch  wide, 
and  of  the  other  three-sixteenths  of  an  inch.  If  the  stenosis  is  confined  to  the  internal 
OS,  the  narrower  blade  alone  is  used.  If  both  ora  are  contracted,  the  wider  instrnment 
is  passed  through  the  external  os,  and  the  other  blade  then  introduced  and  the  inner 
OS  incised  by  it;  and  in  cases  of  decided  congestion,  the  wider  blade  alone  is  sometimes 
used  for  both  ora.  In  this  case,  a  sound  one-fifth  of  an  inch  in  diameter  is  easily 
passed  through  the  inner  os,  wliile,  if  tiie  smaller  blade  had  been  used,  considerable 
force  would  be  required  to  carry  it  through. 

"In  hospital  practice  I  place  the  patient  upon  the  side,  use  the  duck-bill  speculum, 
hold  the  cervix  by  means  of  a  uterine  tenaculum,  pass  the  tube  into  the  canal  up  to 
tlie  shoulder,  and,  therefore,  one-quarter  of  an  inch  into  the  uterine  cavity  through 
the  internal  os,  when  the  blade,  previously  gauged,  is  introduced  into  the  tube  and 
carried  up  the  cervical  canal  as  far  as  is  required  to  overcome  the  stenosis.  My  large 
sound  (No.  10,  American  scale),  or,  still  better,  the  conical  dilator  of  the  proper  size, 
is  then  passed  up  the  canal,  and  the  operation  is  completed.  In  private  practice  I 
generally  place  the  patient  on  the  back,  and  pass  the  tube  into  the  cervical  canal  pre- 
cisely as  I  would  Simpson's  sound,  and  then  pass  the  blade  through  it,  as  just 
described. 

"If  the  external  os  is  too  narrow  for  the  admission  of  the  extremity  of  my  instru- 
ment, it  may  be  enlarged  by  the  introduction — generally  one-eighth  to  one-quarter  of  an 
inch  is  far  enough — of  a  narrow-pointed  bistoury.  I  have  not  found  the  internal  os 
too  narrow  to  receive  it,  except  in  cases  of  flexion,  or  previous  traumatic  injury  of  the 
cervix. 

"  The  changes  in  the  whole  uterine  cavity  from  this  operation  are  shown  by  Fig. 
198.  Respecting  its  dangers  I  have  but  little  to  communicate.  The  hemorrhage 
following  it  seldom  exceeds  one  or  two  drachms,  and  never  requires  any  special  atten- 
tion. The  pain  is  ver}'  slight  and  momentary,  and  no  anaesthetic  is  ever  required. 
The  medullary  structure  of  the  cervix  never  being  cut  into,  pelvic  cellulitis  and  peri- 
tonitis do  not  ensue.  The  only  exceptions  to  this  statement  in  nearly  three  hundred 
cases  are:  one  case  in  private  practice,  in  which  some  febrile  reaction  and  uterine 
tendeirness  ensued,  which  subsided  entirely,  without  cellulitis,  in  four  days ;  and  two 
cases,  in  the  Woman's  Hospital,  of  slight  cellulitis.  But  both  the  latter  were  patients 
who  were  known  to  have  had  cellulitis  a  short  time  previously,  and  I  was  obliged,  by 
some  peculiar  circumstances,  to  operate  sooner  than  I  otherwise  would  have  done. 
The  final  results  were  precisely  as  desired  in  each  of  these  three  cases.  Otherwise  I  have 
never  had  any  unpleasant  symptoms  follow  the  operation;  and  the  only  precautions 
taken  are  to  keep  the  patient  two  days,  and  sometimes  three  days,  in  bed,  and  not 
allow  her  to  walk  out  under  a  week.  I  use  tlie  dilator  every  second  day  after  the 
operation  for  a  week,  and  two  or  three  times  more  once  a  week.  I  have  very  often 
performed  the  operation  at  my  office  on  residents  of  the  city,  and  sent  the  patient 
home  to  bed  after  half  an  hour's  rest,  and  have  never  had  to  regret  it.  I  decline  to 
operate  within  four  days  after  or  six  days  before  the  catamenial  period. 

"I  claim  for  the  method  just  described  the  following  recommendations  in  the  treat- 
ment of  stenotic  sterility  and  dysmenoiTlioaa. 

"  I.  It  aims  to  restore  the  normal  dimensions  as  existing  in  the  parous  woman 
throughout  the  cervical  canal,  nothing  more  and  nothing  less,  unless  where  a  slight 
exaggeration  of  size  is  required  on  account  of  coexisting  congestion. 

"II.  It  effects  tliis  object  definitely  and  with  certainty,  and  with  incisions  exactly 
symmetrical,  or  equal  on  the  two  sides. 

"  III.  It  gives  no  danger  from  hemorrhage,  since  the  arteries  nearest  tlie  internal 
OS,  if  that  is  to  be  divided,  are  never  reached,  and  the  whole   thickness  of  the  lining 


peaslee's  method. 


325 


membrane  even  is  generally  not  divided  ;  and  there  are  no  arteries  within  the  portion 
divided  at  the  external  os. 

"IV.  There  is  no  danger  of  pelvic  cellulitis,  except  in  those  patients  in  whom  the 
least  operative  interference  with  the  cervix,  or  the  use  of  the  sound  or  of  a  sponge- 
tent,  will  produce  it.  I  consider  the  operation  less  dangerous  in  this  respect  than  the 
last  mentioned. 

Fig.  197.  '  Fig.  198. 


Normal  Uterine  Cavity. 
Fig.  199. 


Ditto,  as  Modified  by  Peaslee's  Method. 
Fig.  200. 


Uterine  Cavity  after  Sims's  Operation. 


Ditto,  after  Simpson's  Operation. 


"  V.  There  is  no  danger  of  septic  peritonitis,  since  the  medullary  substance  is  not 
reached  by  the  incision. 

"VI.  It  does  not  produce  sterility  or  tendency  to  abortion  by  mutilating  the  cervical 
canal.  The  changes  it  produces  in  the  latter,  as  compared  with  those  from  the  opera- 
tions of  Simpson  and  Sims,  are  shown  by  Figs.  197,  198,  199,  and  200. 


326  DYSMENORRHCEA. 

"  VITI.  It  removes  stenosis  perfectly,  and  in  most  cases  permanently,  since  there  is 
very  little  tendency  to  closure  of  the  slight  incision  made.  I  have  had  to  repeat  the 
operation  only  twice  in  my  practice,  except  in  cases  in  which  there  was  cicatricial 
tissue  to  be  divided,  as  after  imperfect  and  partial  closure  following  rupture  of  the 
cervix  in  parturition,  or  ensuing  after  Simpson's  or  Sims's  operations.  Here  the  opera- 
tion will  usually  have  to  be  repeated  in  a  year  or  two,  unless  pregnancy  should  occur, 
an  event  not  to  be  expected  in  such  cases,  as  we  have  seen. 

"Finally,  then,  since  my  experience  has  shown  that  a  diameter  of  one-fifth  of  an 
inch  for  the  internal  os,  and  of  one-quarter  to  three-tenths  of  an  inch  for  the  external 
OS,  is  sufficient  in  the  treatment  of  stenotic  sterility  and  dysmenorrhoea,  I  suggest  the 
disuse  of  Simpson's  and  Sims's  operation  in  the  treatment  of  these  conditions,  and  the 
substitution  of  a  milder,  safer  and  more  efficacious  method,  of  which,  perhaps,  ray 
own  is,  however,  only  the  forerunner.  At  least,  further  experience  in  the  line  I  have 
indicated  will  doubtless  affijrd  still  more  accurate  conclusions." 

Dilatation. 

Dilatation  is  a  very  effective  means  of  overcoming  uterine  stenosis, 
when  either  simple  or  complicated  with  flexions  or  displacements, 
when  properh^  done.  It  is  certainly  safer,  and  I  believe  more  effectual 
in  most  cases  than  any  method  of  cutting.  Dilatation  may  be  accom- 
plished by  repeated  efforts,  continued  at  intervals  for  several  weeks  or 
months,  or  at  one  sitting.  According  to  the  first  plan,  dilatation  is 
effected  once  a  week  or  oftener  until  the  cervical  cavity  is  sufficiently 
patent  and  so  remains.  This  method  has  the  advantage  that  it  is  not 
attended  with  much  pain,  nor  followed  by  serious  inconvenience  of 
any  kind.  Indeed,  with  reasonable  regard  to  the  force  used,  there  will 
be  no  danger  in  doing  it  in  the  office  and  permitting  the  patient  to 
return  home.  In  all  cases,  however,  where  moderate  but  decided 
dilatation  is  done,  the  patient  should  lie  upon  a  lounge  or  bed  until 
all  pain  and  uneasiness  have  subsided.  There  is  no  doubt  but  that 
this  trifling  operation  had  better  be  done  at  the  home  of  the  patient. 
Tents,  hard  rubber  or  steel  sounds  may  be  used  for  this  purpose.  Of 
the  tents  I  would  recommend  the  slippery  elm  as  being  quite  efficient 
and  painless,  and  I  know  of  no  other  tent  now  in  use  attended  with 
the  same  immunity.  The  sponge,  sea-tangle,  or  tupelo  tents  are  fraught 
with  much  danger,  especially  when  it  becomes  necessary  to  repeat 
their  employment.  The  elm  tent  has  the  advantage  of  great  flexibil- 
ity as  compared  with  the  others.  (See  description  and  mode  of  using, 
Chapter  IV.,  Figs.  96  and  97.)  The  well-known  success  of  Dr.  Mackin- 
tosh with  graduated  steel  sounds,  as  practiced  fifty  j^ears  ago,  if  noth- 
ing more  were  said  of  them,  has  established  their  reputation.  To 
effect  sudden  dilatation  these  instruments  may  be  used  quite  advan- 
tageousl3^  To  make  sudden  dilatation  safe  with  these  or  any  other 
instruments,  the  preparation  and  subsequent  treatment  should  be  the 
same  as  for  any  other  important  surgical  operation,  and  no  means  left 
undone  to  prevent  septic  or  inflammatory  consequences. 

The  operation  of  dilating  the  cervical  canal  with  bladed  instruments 


DILATATION. 


327 


is  a  simple  mechanical  procedure,  easily  executed,  and  on  the  whole 
more  satisfactory  than  with  sounds,  tents,  or  bougies,  except  the  slip- 
pery elm  tents.  There  are  a  large  number  of  instruments  for  this 
purpose,  mostly  two  bladed,  although  some  have  three  or  more  blades. 
Hunter's  and  Goodell's  instruments  are  both  excellent.  The  main 
difference  between  them  is  that  Goodell's  has  blades  with  corrugated 
surfaces  to  keep  them  from  slij)i3ing  out  while  being  separated.  Dr. 
Goodell's  is  made  in  two  sizes,  the  small  one  for  cases  in  which  mod- 
erate dilatation  is  required,  and  to  precede  the  larger  one  when  the 
passage  is  too  small  to  admit  it.  For  slow  dilatation  these  instru- 
ments may  be  used  through  the  common  speculum  three  or  four 
times  a  month,  and  the  cervix  dilated  to  one-fourth  of  an  inch  for  the 
first  few  times,  and  afterwards  half  an  inch.  Each  sitting  should  last 
ten  minutes  or  more  with  the  administration  of  an  anodyne  when 
there  is  pain,  and  the  precautions  of  quietude  always  for  at  least  half 
an  hour  after.  When  the  blades  of  the  instruments  are  passed  beyond 
the  internal  os  uteri,  and  the  manipulations  continued  sufficiently 


Fig.  201. 


Goodell's  Dilator. 


long,  success  is  likely  to  follow.  The  operation  for  sudden  and  exten- 
sive dilatation  is,  of  course,  a  much  shorter  way  to  the  object  than 
this,  and  while  more  hazardous,  is  very  efficacious. 

After  being  etherized,  the  patient  should  be  placed  on  her  back  on 
a  table  with  the  perineum  projecting  slightly  over  the  end  of  it.  The 
vagina  should  be  dilated  by  Simon's  instruments,  and  the  cervix 
seized  by  a  light  vulsell,  drawn  slightly  down  toward  the  vulva  and 
held  firmly.  This  traction  generally  reduces  the  cervical  flexion  to 
such  a  degree  as  to  permit  the  blades  of  the  instruments  to  pass  the 
contracted  part  and  enter  the  cavity  of  the  bod3^  After  this  com- 
plete entrance  is  manifest  the  blades  should  be  slowly  separated  until 
the  required  amount  of  dilatation  is  effected.  The  instruments  should 
be  allowed  to  remain  in  this  position  for  ten  or  fifteen  minutes.  They 
should  then  be  introduced  with  the  curve  of  the  blades  reversed, 
and  also  turned  half  around,  and  similarly  expanded.  The  extent 
to  which  this   distension  should  be   carried  will  depend  to  a  great 


328  DYSMENOEEHCEA. 

extent  upon  the  severity  of  the  symptoms  of  obstruction.  Dr.  Goodell 
advises  from  three-quarters  to  one  and  a  half  inches.  I  think  it 
ought  also  to  depend  on  the  condition  of  the  cervix — very  small 
pointed  cervices  dilate  badly,  and  may  be  torn  by  extensive  stretch- 
ing, while  in  patients  who  have  had  children,  there  is  not  so  much 
difficulty.  The  time  for  operating  is  soon  after  the  menstrual  period 
has  passed.  After  the  operation  the  patient  should  be  put  to  bed,  and 
carefully  guarded  against  attacks  of  pelvic  inflammation  or  other  evil 
consequences. 

Another  means  of  dilating  and  straightening  the  uterus  to  overcome 
the  stenosis  caused  by  flexion,  is  the  stem  pessary.  The  value  of  this 
instrument  has  been  the  subject  of  much  discussion;  some  gynecolo- 
gists condemning  it  altogether,  and  giving  potent  arguments  against 
it,  while  others  speak  of  it  as  the  best  of  all  means  and,  where  prop- 
erly used,  entirely  harmless.  There  is  no  question  that  the  difference 
in  estimating  its  worth  depends  largely  upon  the  manner  of  managing 
it.  The  danger  and  not  the  efficiency  of  the  instrument  is  the  point 
in  the  dispute.  Winckel*  puts  the  subject  in  its  proper  light  when  he 
says  by  careful  preparation,  and  the  proper  selection  of  cases,  the  use 
of  the  intrauterine  stem  is  free  from  danger,  while  from  carelessness  on 
the  part  of  the  physician  or  the  patient  it  may  give  rise  to  months  of 
sufiFering.  He  considers  the  evil  consequences  to  be  "  hemorrhages, 
colicky  pains,  parametric  exudation,  and  occasionally  peritonitis," 
and  he  might  have  added  metritis.  In  fifty  cases  in  his  own  practice 
he  has  met  with  but  two  cases  of  parametritis.  Prof.  A.  Reeves 
Jackson  read  a  paper  upon  this  subject  before  the  Chicago  Medical 
Society,  June  7, 1886,  giving  the  results  of  this  treatment  in  sixty-four 
cases.  Of  the  entire  number,  a  cure  of  the  flexion  followed  in  forty, 
four  were  improved  and  relieved  of  dysmenorrhcea  which  before  had 
been  constant.  In  twenty  the  result  was  unknown.  Dr.  Jackson 
prefers  Chambers's  bifurcated  vulcanized  instrument.  The  short 
glass  stem  recommended  by  Dr.  Chamberlin  and  Prof.  Thomas,  of 
New  York,  is  a  very  neat  and  effective  one,  and  will  usually  be  toler- 
ated as  easily  as  any  other. 

The  patient  should  be  prepared  for  the  use  of  the  stem  by  remov- 
ing inflammation  when  present,  by  hot  water  douches  and  glycerine 
cotton  tampons  for  a  sufficient  time.  Immediately  prior  to  introduc- 
ing the  instrument  the  rectum  should  be  emptied,  and  the  vagina  and 
vulva  disinfected  with  carbolized  water. 

To  adapt  the  instrument,  the  patient  should  be  placed  in  Sims's 
position,  the  vagina  dilated  with  Sims's  speculum,  and  the  uterus 
drawn  down  and  fixed  by  a  small  vulsell  forceps.  This  will  some- 
what reduce  the  flexion,  when  we  may  pass  the  sound  and  measure 

*  Lehrbncli  der  Frauen  Krankheiten.     Leipzig,  1886,  p.  331. 


DILATATION.  329 

the  length  and  size  of  the  uterine  cavity.  A  stem  should  be  selected 
that  is  nearly  half  an  inch  shorter  than  the  measurement,  and  with 
the  dressing  forceps  placed  in  position.  To  keep  the  instrument  from 
being  expelled,  a  tampon  of  borated  cotton  should  be  placed  against 
it,  and  left  in  that  position  for  twenty-four  hours.  The  tampon 
should  then  be  removed  by  placing  the  patient  under  the  same  con- 
ditions with  reference  to  position  as  for  the  introduction.  After  that 
the  stem  will  generally  remain  in  place.  If  it  does  not  the  tampon 
may  be  used  again.  The  patient  ought  to  remain  in  bed  for  several 
hours  after  the  instrument  has  been  placed. 


CHAPTEE   XIII. 

METATITHMENIA  {yurarceni,^  y.r,y)  -.  OR,  MISPLACED  MENSTRUATION. 
PERIUTERINE  H.EMATOCELE. 

The  accident  to  which  I  apjjly  the  above  terms  is  an  effusion  of 
blood  in  tissues  around  and  above  the  uterus,  the  effusion  being  some- 
times very  extensive,  at  others  limited  to  a  small  space.  The  effusion 
may  take  place  in  the  vaginal  wall,  between  the  vagina  and  rectum, 
tearing  up  their  connecting  tissue,  or  in  the  posterior  wall  of  the 
uterus,  beneath  the  peritoneum,  or  between  the  peritoneal  layers  of 
the  broad  ligament  beside  the  uterus,  or  in  the  jDeritoneal  cavity. 
The  mode  of  the  accident  varies  somewhat,  owing  to  the  locality  in 
which  this  blood  is  found.  The  blood  is  effused  in  interspaces 
beneath  the  peritoneum  and  elsewhere,  as  the  effect  of  a  rupture  of 
some  vessel;  but  while  the  effusion  ma}^  be,  and,  perhaps,  generally 
is,  the  result  of  a  ruptured  vessel  of  the  ovary,  the  blood  sometimes 
also  arrives  in  the  peritoneal  cavity  from  the  uterus  through  the 
Fallopian  tubes.  We  are  not  yet  able  to  decide  which  of  these  cir- 
cumstances is  the  more  common. 

This  accident  happens  most  frequently  at  the  time  of  menstruation, 
or  very  near  it.  As  an  accompaniment  of  menstrual  congestion,  the 
bloodvessels  of  the  whole  genital  organs  are  greatly  distended,  and  in 
certain  cases  this  turgidity  becomes  too  great  for  their  capacity,  and 
a  rupture  is  caused  at  some  particular  place ;  or,  the  cavity  of  the 
uterus  being  filled  with  a  profuse  flow  into  it,  the  blood  regurgitates 
through  the  tubes  into  the  peritoneum.  It  is  not  likely,  however, 
that  any  considerable  effusions  are  thus  caused,  so  that  the  sudden 
and  copious  collections  sometimes  observed  must  be  accounted  for 
upon  the  supposition  that  a  small  arterial  twig  has  given  way  in  the 
ruptured  ovisac  at  the  time  of  the  escape  of  the  ovum,  and  poured  the 
fluid  rapidly  into  the  sac  formed  behind  the  uterus  by  the  descent  of 
the  peritoneum.  The  instances  I  have  observed  were  more  frequently 
connected  with  cases  of  disordered  menstruation,  but  I  have  also  seen 
the  accident  in  patients  whose  menses  seemed  normal. 

Dysmenorrhoea  may  be  regarded  as  the  most  common  deviation 
accompanying  misplaced  menstruation. 

There  can  be  no  doubt  but  that  effusions  of  blood,  in  every  respect 
similar  to  misplaced  menstruation,  are  caused  by  the  condition  of  the 
uterus  and  appendages  in  abortion,  after  labor,  and  as  the  result  of 
other  causes  of  intense  congestion ;  but  when  so  the  modus  in  quo  is 
precisely  the  same,  the  congestion  being  caused,  not  by  the  menstrual 


MENSTRUATION    AND    ITS    DISORDERS.  331 

molimen.  but  by  the  congestion  of  pregnancy  and  morbid  excitement 
which  sometimes  attend  these  two  states, — rupture  of  a  small  vessel 
or  regurgitation  being  the  immediate  condition. 

Sanguineous  collections  arising  in  this  way  may  be  minute  in  size, 
but  sometimes  the  quantity  of  blood  is  dangerously  and  even  fatally 
large.  The  small  collections  are  forced  into  places  where  distension 
is  most  difficult,  as  in  the  cellular  tissue,  while  the  large  effusions  are 
met  with  in  the  peritoneal  cavity.  Immediately  after  the  blood  is  ex- 
travasated  changes  begin  to  take  place  in  it  and  in  the  tissues  occupied 
by  it.  Inflammation  to  a  greater  or  less  degree  almost  always  is  the 
result.  In  a  mild  grade  the  inflammation  causes  an  eff"usion  of  serum? 
which  augments  the  bulk  of  the  accumulation  and  gives  the  appear- 
ance of  much  blood,  when  in  reality  there  is  but  a  small  quantity. 
When  this  is  the  state  of  things,  the  disappearance  of  the  tumor  by 
absorption  may  be  expected  in  a  comparatively  short  time,  and  we 
often  see  it  removed  in  a  very  few  weeks. 

Dr.  G.  Bernutz  has  lately  studied  the  pa,thology  of  uterine  hemato- 
cele, and  presents  his  views  in  a  series  of  interesting  articles  (Arch, 
de  Tocol,  March,  April,  and  May,  1880).  The  most  important  con- 
clusions of  this  study  are  summarized  by  Bernutz  as  follows : 

"1.  Intraperitoneal  uterine  hsematocele  may  arise  in  two  entirely  distinct  and 
different  ways. 

"2.  In  one  case,  which  may  be  termed  '  classic  '  hematocele,  liemorrhage  takes  place 
from  rupture  of  the  products  of  extrauterine  gestation,  or  from  rupture  of  some  of  tjie 
internal  organs  of  generation,  or  the  escape  of  the  blood  which  had  distended  tiie 
oviducts  into  the  abdominal  cavity,  where  a  secondary  peritonitis  is  set  up  by  its 
presence,  this  inflammation  leading  to  incapsulation  of  the  bloody  collection. 

"3.  In  other  cases  the  hematocele  is  the  result  of  a  primary  pelvi-peritonitis,  the 
hemorrhage  occurring  at  a  period  more  or  less  remote  from  the  incipience  of  the 
serous  inflammation.  In  this  case  the  disease  is  a  secondary  manifestation  of  inflam- 
matory action,  audits  true  origin  is  found  in  the  newly-formed  membi'anes  lining  the 
pelvic  peritoneum. 

"4.  These  neomembranous  hematoceles  may  be  symptomatic  of  vai-ious  conditions. 
Thus  they  may  indicate  an  acute  pelvi-peritonitis  in  a  woman  who  was  previously 
attacked  by  a  more  or  less  severe  inflammation  of  the  pelvic  peritoneum,  or  they  may 
point  to  a  repetition  of  former  subacute  inflammations,  or,  in  fine,  to  a  chronic  pelvic 
peritonitis  of  a  particular  kind.  There  are,  therefore,  two  varieties  of  hematocele 
symptomatic  of  pelvi-peritonitis,  each  of  which  has  a  pathogenesis  of  its  own. 

"c.  In  the  hematoceles  denoting  an  acute  or  subacute  peritonitis,  the  hemorrhage 
arising  in  the  newly-formed  membrane  is  from  the  outset  rather  profuse,  being  com- 
monly determined  by  menstrual  congestion.  For  this  reason  an  intraperitoneal  hema- 
toma becomes  at  once  manifest.  Frequently  it  becomes  a  matter  of  difBcult}'  to  dis- 
tinguish between  the  two  kinds  of  hematocele  unless  the  period  of  incipiency  has  been 
observed  by  the  physician.  Fortunately  the  practical  importance  of  this  fact  is  not 
very  great,  since  the  treatment  is  essentially  similar  in  both  varieties  of  the  disease. 
In  the  second  form  of  hematoceles,  which  alone  exactly  corresponds  to  Virchow's  de- 
scription, the  hematoma  is  tlie  result  of  scarcely  suspected  morbid  action,  which  is  very 
well  indicated  by  the  name  of  hemorrhagic  pachy-pelviperitonitis.  Under  the  influence 


332  METATITHMENIA. 

of  this  chronic  process  the  pelvic  peritoneum  is  occupied  by  stratified  patches  of  new- 
formed  membrane.  In  this  way  it  becomes  thickened,  as  it  were,  and  slight  hemorrhage 
takes  place  between  the  superimposed  lamellse,  thus  forming  interstitial  blood-cysts. 
These  hematoceles  are  strictly  analogous  to  similar  tumors  of  the  tunica  vaginalis.* 

The  intensity  of  the  inflammation  is  frequently  much  greater,  pro- 
ceeding through  the  stage  of  serous  effusion  to  the  production  of 
fibrinous  deposit.  A  hard  tumor  is  the  result.  This  again  may  re- 
main for  a  longer  or  shorter  time,  and  then  very  slowly  disappear,  or 
only  be  partially  taken  away,  leaving  a  permanent  hardness,  or,  what 
is  not  unfrequently  the  case,  proceed  to  suppuration  and  discharge  in 
some  way. 

I  have  seen  as  many  as  two  cases  terminate  fatally  by  the  exhaus- 
tion of  suppurative  fever  without  the  discharge  of  the  contents  of  the 
tumor.  When  suppuration  is  fairly  established  by  the  inflammation 
thus  arising,  exulceration  and  evacuation  follow  as  a  general  rule. 
The  vagina  is  most  frequently  perforated  by  the  ulcerative  process, 
but  the  jectum,  bladder,  or  uterus  may  serve  as  the  conduit  of  dis- 
charge. If  the  inflammation  is  of  an  acute  character,  and  the  steps 
in  the  process  of  evacuation  rapidly  succeed  each  other,  the  character 
of  the  discharge  will  partake  largely  of  a  bloody  quality ;  but  should 
the  time  required  by  exulceration  be  considerable,  pus  will  prevail  in 
the  composition.  In  any  case,  however,  the  discharge  is  a  mixture  of 
pus  and  changed  blood.  This  last  is  sometimes  very  greatly  changed, 
sometimes  but  slightly.  In  rare  instances  the  j)eritoneum  is  inundated 
by  rupture  into  its  cavity  of  this  mixture  of  pus  and  blood,  and  over- 
whelmed with  a  general  inflammation,  soon  resulting  in  death.  I 
have,  seen  cases  of  this  kind,  which  were  verified  by  post-mortem  ex- 
amination. 

After  absorption  in  cases  attended  with  the  milder  grade  of  inflam- 
mation, very  slight  traces,  if  any,  can  be  found  by  examination  of 
the  patient.  When  effusion  of  fibrin  takes  place,  displacements,  per- 
manent adhesions  of  the  uterus  and  other  parts,  and  deformity,  will 
be  left  behind,  slight  or  considerable,  as  the  amount  of  deposit  was 
small  or  great.  These  changes  will,  of  course,  be  greater  after  the 
process  of  suppuration  and  discharge  has  been  reached  by  the  inflam- 
mation. Fistulous  and  tortuous  openings  may  also  embarrass  the 
convalescence  of  the  patient,  or  even  by  their  long  continuance  ex- 
haust her. 

Symptoms. 

The  symptoms  vary  in  different  instances.  The  attack  is  generally 
sudden  and  well  marked.  During  the  menstrual  flow,  or  it  may  be 
just  before  or  after,  the  patient  is  seized  with  severe  pain  in  the  hypo- 

*  American  Journal  of  Obstetrics,  January,  1881. 


SYMPTOMS.  333 

gastrium  or  one  of  the  iliac  regions.  Frequently  there  is  also  a  sense 
of  faintness,  sometimes  slight,  but  often  it  amounts  to  complete  syn- 
cope. In  the  place  of  faintness  there  are  sometimes  coldness,  tremors 
and  palpitation  of  the  heart.  The  i^ain  becomes  persistent,  and,  per- 
haps, less  severe,  but  not  unfrequently  it  increases  for  a  considerable 
time  and  then  gradually  diminishes.  After  the  inception  the  pain 
usually  spreads  over  the  abdomen  to  the  back  and  hips,  and  some- 
times down  the  thigh  and  leg.  As  the  pain  becomes  greater  or  extends 
over  a  greater  space,  febrile  reaction  is  developed,  generally  moderate 
in  grade,  but  occasionally  excessive;  the  pulse  becomes  rapid,  the 
heat  considerable,  and  the  patient  complains  of  great  depression  and 
thirst.  The  abdomen  increases  in  size  and  becomes  tympanitic,  while 
there  may  be  a  distinct  tumidity  and  hardness  felt  in  one  of  the  iliac 
regions ;  sometimes  the  hardness  extends  over  the  hypogastric  to  the 
other  iliac.  This  hardness  and  swelling  may  scarcely  rise  above  the 
pelvic  brim,  but  it  not  unfrequently  is  perceived  extending  as  high  as 
the  umbilicus.  It  is  not  much,  if  at  all,  tender  to  the  touch.  It  is 
irregular  in  its  outline  also.  In  very  rare  instances  the  etfusion 
takes  place  slowly,  the  symptoms  are  developed  quite  gradually,  and 
the  time  of  the  beginning  is  not  so  definite,  but  the  subsequent  course 
is  apt  to  be  the  same. 

After  the  symptoms  are  fully  manifested,  they  pursue  a  course  cor- 
responding to  the  grade  of  inflammation  which  is  awakened  by  the 
eflFusion.  In  some  cases  the  inflammation  around  the  effusion  is  active 
and  intense,  and  continues  with  severity  until  suppuration  and  exul- 
ceration  end  the  process.    Obstinate  constipation  is  frequently  present. 

Of  course  the  fever  is  corresponding  in  grade  and  persistence,  pass- 
ing through  the  high  grade  to  hectic,  attended  with  all  its  exhausting 
discharges.  If  the  inflammation  is  less  acute,  the  fever  may  be  per- 
sistent for  weeks,  and  sometimes  for  months,  but  of  more  moderate 
grade,  until  it  gradually  subsides,  or  slowly  ends  in  suppuration  and 
discharge.  Active  exercise  aggravates  the  symptoms.  Fortunately,  in 
the  large  majority  of  cases,  the  amount  of  the  effusion  is  small,  the  grade 
of  inflammation  slight,  and  the  duration  but  a  few  days  or  weeks. 

There  are  two  ways  in  which  individuals  are  rendered  miserable 
by  the  frequent  recurrence  of  this  trouble..  One  is,  when  all  the 
symptoms  subside  entirely  for  months,  and  then  return.  The  tumor 
entirely  disappears,  the  inflammation  is  wholly  gone,  and  the  patient 
feels  that  she  has  fully  recovered  her  health,  when,  suddenly,  during 
a  menstrual  flow,  she  is  again  seized  with  pain,  swelling,  fever,  etc., 
which  again  subsides  to  be  repeated  more  or  less  frequently.  I  have 
a  patient  who  has  suffered  attacks  of  this  sort  perhaps  twenty  times 
in  the  last  six  or  seven  years,  in  whom  the  tumors  have  at  different 
times  been  mistaken  for  ovarian  or  uterine  tumors.  In  the  other  way 
the  subsidence  is  only  partial;  there  is  all  the  time  some  tumidity. 


334  METATITHMENIA. 

some  inflammation,  and  more  or  less  sympathetic  suffering,  with  occa- 
sional severe  returns.  More  blood  is  effused,  the  tumor  is  increased 
in  size,  and  the  inflammation  intensified,  and  all  subside  to  a  partial 
extent  and  return  again. 

When  the  tumor  is  much  inflamed  and  suppurates,  it  may  suddenly 
discharge  through  the  vagina ;  all  the  urgent  symptoms  readily  sub- 
side, and  the  patient  becomes  convalescent.  Again,  the  discharge  is 
sometimes  slow  and  difficalt,  the  relief  is  imperfect,  and  a  protracted 
convalescence  the  result.  But  sometimes,  after  a  course  correspond- 
ing to  the  above  description,  sudden  and  general  peritonitis  is  lighted 
up  by  extension  of  inflammation  from  the  sac,  or  a  discharge  of  some 
of  its  contents  into  the  peritoneal  cavity. 

The  discharge  is  generally  fetid  and  highly  irritating,  consisting  of 
partially  decomposed  blood,  pus,  and  ichor.  It  is  always  offensive 
compared  with  discharges  from  an  ordinary  abscess.  I  have  seen  one 
or  two  instances  in  which  the  general  symptoms  were  not  manifested 
at  all,  nor  did  the  pain  amount  to  anything  more  than  an  incon- 
venience, not  very  difficult  to  bear. 

It  is  interesting  to  observe  the  effects  of  this  misplaced  menstrua- 
tion upon  the  flow  pe)^  vias  naturales.  Occasionalh'-  no  effect  seems  to 
be  produced,  the  flow  being  natural  in  quantity  and  duration ;  in 
fact,  it  is  just  at  the  time  of  the  cessation  of  the  discharge  that  effu- 
sion into  the  tissues  takes  place,  but  at  other  times  there  continues  for 
many  weeks  a  constant  stillicidium  of  blood.  Or,  occasionally, — 
when  the  menses  occur  during  the  course  of  the  symptoms, — the 
amount  of  discharge  is  very  much  increased.  I  knew  one  patient  that 
had.  a  constant  slight  sanguineous  discharge  from  the  vagina  for  six 
months,  and  at  the  regular  menstrual  periods  copious  hemorrhages. 
In  some  cases  the  flow  is  more  scanty  than  usual. 

Diagnosis. 

There  are  several  conditions  with  which  this  sanguineous  efllision 
may  be  confounded,  if  some  caution  is  not  observed.  Inflammation  of 
pelvic  cellular  tissue,  or  pelvic  abscess,  are  the  ones  most  likely  to  be 
mistaken  for  metatithmenia,  or  this  last  for  the  first.  And  as  I  have 
already  shown,  abscess  is  sometimes  the  result  of  misplaced  menstrua- 
tion, the  effusion  in  the  tissues  exciting  intense  inflammation,  which 
proceeds  to  the  stage  of  suppuration. 

In  cellulitis  the  inflammation  is  not  ordinarily  ushered  in  by  the 
same  suddenly  occurring  acute  pain  and  faintness.  Chilliness  and 
fever  are  more  marked  from  the  beginning,  the  pain  usually  com- 
mencing after  the  fever  has  begun,  or,  at  least,  increasing  after  the 
fever  is  established.  The  tumor  above  the  linea  ilio-pectinea  is  not 
perceptible  for  many  hours,  oftener  one  o,r  two  days ;  it  is  extremely 
tender,  and  even  in  its  outline. 


PEOGNOSIS.  335 

In  metatithmenia  the  tumor  is  observed  in  a  few  hours,  and  is  not 
so  very  tender  to  the  touch.  It  may  be  handled  and  pressed  upon 
much  more  freely  than  the  tumor  of  simple  inflammatory  origin.  If 
examined  per  vaginam  the  inflammatory  hardness  and  swelling  is 
very  firm.  It  is  usually  lower  down  and  more  to  one  side.  The 
tumor  from  sanguineous  efl'usion  is  quite  elastic  at  first,  and  presents 
an  edgelike  projection  down  behind  the  uterus,  entirely  below  the  os 
and  cervix.  The  finger  may  be  pushed  up  between  the  cervix  and 
the  tumor,  and  the  thick  convex  edge  of  the  latter  reminds  one  of  a 
thick  cake.  There  is  very  little  tenderness,  and  vessels  may  almost 
always  be  felt  pulsating  over  this  projection.  I  need  not  say  that  this 
is  never  the  case  in  the  early  stages  of  cellulitis.  The  vessels  in  this 
last  are  obliterated  by  fibrinous  and  serous  effusion. 

If  inflammation  of  a  high  grade  speedily  follows  the  effusion  of 
blood  in  the  tissues,  the  symptoms  of  the  two  may  be  so  intimately 
blended  as  to  make  it  doubtful  how  the  tumor  begau,  and,  in  fact,  it 
may  be  converted  into  pelvic  abscess. 

Tumors  of  the  uterus,  under  certain  circumstances,  may  be  con- 
founded with  the  tumor  of  sanguineous  effusion;  but  their  firmness, 
the  want  of  conformity  to  the  shape  usually  assumed  by  this  last,  the 
enlargement  of  the  uterine  cavity,  our  ability  to  isolate  them  by  the 
fingers  and  probe,  their  gradual,  unperceived  growth,  and  their  mo- 
bility, will  almost  always  suffice  to  make  the  distinction  manifest. 

From  ovarian  tumors  it  may  be  distinguished  by  the  more  regular 
outline,  fluctuation  on  percussion,  less  grave  symptoms,  gradual  de- 
velopment, absence  of  the  projecting  edge  behind  the  uterus,  the  want 
of  the  beating  vessels,  etc.,  in  ovarian  growths. 

Displacements  of  the  uterus  may  always  be  made  out  with  great 
certainty  by  introducing  the  probe  into  its  cavity  to  ascertain  the  di- 
rection of  the  fundus,  and  correcting  its  deviations.  Hence  the  diag- 
nosis need  not  be  long  embarrassed  by  any  question  in  reference  to 
them.  Retroversion  of  the  impregnated  uterus  is  constantly  attended 
with  great  urinary  distress,  while  metatithmenia  seldom  is. 

Extrauterine  pregnancy,  perhaps,  in  some  instances,  more  nearly 
resembles  it  than  any  other,  but  the  enlarged  and  flaccid  cervix,  open 
OS,  dark  color,  and  enlarged  cavity,  in  this  sort  of  pregnancy,  and 
their  absence  in  the  accident  we  are  considering,  will  suffice  to  dis- 
tinguish between  them. 

Prognosis. 

The  dangers  to  be  apprehended  in  uterine  ha3matocele  arise  from : 
1st,  the  shock  of  the  effusion  in  the  peritoneal  cavity,  which,  however, 
is  not  generally  considerable ;  2d,  fatal  exhaustion  from  the  amount 
of  effusion  in  the  abdominal  cavity ;  and,  8d,  inflammation  and  its 
effects.  From  inflammation  we  may  fear  death,  permanent  damage 
to  the  organs  about  the  pelvis,  and  great  suffering.     Very  few  patients 


336  METATITHMENIA. 

escape  without  protracted  suffering,  often  for  weeks,  and  sometimes 
months. 

Damage  to  a  greater  or  less  degree  frequently  follows  the  displace- 
ments, adhesions,  perforations,  and  thickening  of  the  uterus,  vagina, 
rectum,  and  bladder.  The  exhaustion  of  protracted  febrile  excite- 
ment; the  perspiration,  diarrhoea,  and  vigils  not  very  seldom  wear 
out  the  vital  resistance,  of  the  patient,  who  is  often  of  a  very  delicate 
constitution ;  or  sudden  and  violent  inflammation  of  the  peritoneum 
overwhelms  and  destroys  her. 

The  prognosis  in  any  given  case  will  be  governed  by  the  intensity 
of  the  symptoms  and  the  comparative  strength  of  the  patient  If  the 
amount  of  the  effusion  be  large,  and  there  be  but  little  inflammation, 
the  prognosis  will  be  more  favorable  than  if  the  effusion  be  small  and 
the  inflammation  great.  In  fact,  we  may  with  great  propriety  form 
our  prognosis  by  the  amount  and  intensity  of  the  inflammation  alone, 
as  it  is  almost  the  only  source  oi  danger. 

As  before  observed,  a  cause  of  death,  though  not  frequent,  should 
nevertheless  be  mentioned  as  influencing  the  general  subject  of  prog- 
nosis in  misplaced  menstruation,  viz.,  a  fatal  amount  of  extravasation 
of  blood  in  the  peritoneal  cavity.  More  than  one  case  is  recorded  in 
which  there  was  fatal  prostration,  coming  on  and  pursuing  its  course 
in  a  few  hours,  which,  when  examined,  revealed,  as  the  source  of  an 
extensive  and  copious  hemorrhage,  the  ruptured  twig  of  an  artery  on 
the  ovary.  Of  the  many  cases  that  come  within  our  observation,  how- 
ever, the  number  that  thus  prove  fatal  are  extremely  few. 

Treatment. 

The  three  great  facts  of  this  accident — hemorrhage,  pain,  and  in- 
flammation— afibrd  us  sufficiently  plain  indications  for  treatment. 
It  is  very  seldom  that  we  are  sent  for,  or  in  any  way  see  these  cases, 
until  after  the  hemorrhage  has  exhausted  itself  or  been  stopped  by 
backward  pressure,  after  filling  up  the  space  into  which  the  bleeding 
takes  place.  Should  we,  however,  meet  with  an  instance  during  the 
hemorrhagic  stage,  it  would  be  very  proper  to  make  use  of  ice  to  the 
pelvic  region,  perfect  quiet,  and  astringents  internally,  until  the  effu- 
sion ceased;  but,  as  I  said  before,  such  opportunities  seldom  offer 
themselves.  The  cases  as  we  ordinarily  see  them  have  proceeded 
through  this  stage ;  the  effusion,  in  fact,  is  generally  accomplished  in 
a  few  moments,  or  at  most  in  very  few  hours.  When  we  see  the 
patient,  she  is  either  suffering  with  pain  and  prostration  or  coldness, 
the  primary  effects  of  the  hemorrhage ;  or  pain,  fever,  and  inflam- 
mation, and  our  treatment  will  be  conducted  according  to  the  con- 
ditions in  these  respects.  Our  resources  in  the  first  condition  will  lie 
in  the  use  of  opium  or  other  anodyne,  to  relieve  the  pain  as  much  as 
may  be  necessary,  and  if  the  j)rostration  or  chilliness  be  considerable, 


TEEATMENT.  337 

to  stimulate  sufficiently  to  establish  equilibrium  in  the  circulation, 
but  not  febrile  reaction.  In  very  many  cases  it  will  be  sufficient  to 
keep  our  patient  quiet,  and  place  her  upon  moderate  anodyne  treat- 
ment, good  nourishing  diet,  and  perhaps,  after  the  first  week  or  two, 
tonics,  and  she  will  slowly  rally  from  the  first  shock,  absorption  of 
the  blood  will  result,  and  she  soon  will  recover  her  health.  In  these 
moderate  cases  we  cannot  be  too  careful  not  to  overdo  the  treatment. 
The  patients  will  generally  recover  spontaneously  in  a  few  days  or 
weeks. 

But  another  class  of  cases  occur,  as  I  have  already  said,  in  which 
inflammation  very  soon  succeeds  the  sanguineous  effusion.  A  knowl- 
edge of  the  mischief  which  this  inflammation' brings  about  should 
make  us  prompt  in  meeting  it  with  appropriate  remedies.  If  the 
inflammation  runs  high,  adequate  antiphlogistic  measures  will  be 
indispensable  to  a  favorable  course.  An  active  cathartic  of  calomel 
and  jalap  or  some  other  alterative  cathartic  should  begin  at  once, 
while  at  the  same  time,  if  deemed  advisable  on  account  of  the  force 
of  reaction,  we  may  apply  a  dozen  or  twenty  leeches.  These  may  be 
followed  by  the  tincture  of  veratrum  viride,  in  doses  of  two  drops 
every  hour,  until  the  pulse  is  brought  down  to  its  natural  frequency 
and  volume,  if  not  below  these  conditions,  and  then  continue  its  use 
in  less  doses,  or  the  same  less  frequently  repeated,  for  some  time. 
According  to  my  observations,  the  most  of  adults  will  be  held  at  this 
point  by  taking  as  little  as  one  drop  an  hour ;  some  will  require  more 
and  some  less.  The  energy  of  this  antiphlogistic  course  must  be 
graduated  by  the  force  of  inflammation ;  but  few  cases  will  require  as; 
much  as  is  described  here.  Should  the  inflammation  advance  to  sup- 
puration, the  remedies  required  will  be  supporting ;  at  first^  sulphuric 
acid  and  quinine,  and  afterwards  these  with  wine  or  other  stimulants, 
nourishing  diet,  etc.  These  cases  are  often  so  protracted,  the  patients 
are  so  much  prostrated,  and  suffer  so  much  pain,  that  great  skill  will 
be  called  for  to  adapt  the  anodynes,  tonics,  and  nutrients  to  the  vari- 
ous conditions  of  the  patient  for  so  long  a  time. 

A  question  associated  with  the  progress  of  inflammation,  and  one 
of  great  importance,  is  the  propriety  of  evacuating  the  fluid.  To 
evacuate  the  blood  soon  after  its  extravasation  would  seem  to  remove 
the  cause  of  inflammation,  and  thus  avoid  it.  To  say  that  an  early 
evacuation  of  the  effusion  would  never  be  proper  is  perhaps  to  assume 
an  extreme  position,  and  there  may  be  cases  where  such  evacuation 
is  advisable,  but  I  think  the  number  requiring  it  must  be  ver}^  few. 
Indeed,  I  should  fear  inflammation,  from  the  sudden  discharge  of  a 
large  amount  of  blood  from  the  peritoneal  cavity,  almost  as  much  as 
if  it  were  allowed  to  remain  in  it.  There  is  another  condition  in 
which  an  operation  for  discharge  of  the  contents  of  the  tumescence 
is  less  a  question  of  doubt,  viz.,  when  pus  has  become  mixed  with 

22 


338  METATITHMENIA. 

the  blood,  on  account  of  inflammation.  It  is  very  important  in 
some  instances  to  puncture  and  discharge  the  fluid.  When  the  pa- 
tient is  being  worn  out  by  the  protracted  course  of  the  disease,  and 
the  sweat  and  diarrhoea  which  so  often  attend  it,  we  must  interfere 
surgically  for  her  relief.  And  again,  when  the  fluid  is  increasing, 
and  the  tumor  rising  in  the  abdominal  cavity,  without  showing  any 
disposition  to  "  point "  in  the  pelvis,  or  any  other  place  where  it  is 
desirable  to  have  it  do  so,  there  is  danger  of  the  discharge  of  the  pus 
and  blood  in  the  peritoneal  cavity  by  rupturing  the  sac  above,  and 
we  must  anticipate  it  by  choosing  the  place  and  mode.  "When  we 
have  determined  to  relieve  the  distension  by  puncture,  we  ought  to 
use  an  exploring-needle  or  trocar  to  ascertain  the  contents  before 
evacuating  them.  After  being  satisfied  by  this  corroboration  of  our 
diagnosis,  we  may  plunge  a  large  trocar,  or  even  a  knife,  into  the 
most  dependent  part  of  the  tumor.  This  point  will  almost  invariably 
be  immediately  behind  the  uterus,  but  occasionally  it  will  be  at  the 
side  of  the  pelvis. 

After  free  puncture,  either  with  the  trocar  or  knife,  the  discharge 
readily  takes  place,  and  the  patient  immediately  experiences  great 
relief.  If  the  puncture  is  made  to  remove  the  blood  before  inflam- 
mation has  begun,  the  evacuation  may  be  more  difficult,  as  it  is  often 
coagulated ;  in  that  case  the  opening  must  be  made  large  with  a  knife, 
and  if  the  blood  does  not  easily  flow,  the  finger  may  be  introduced 
to  break  up  the  clots  and  facilitate  their  expulsion.  After  the  con- 
tents are  thus  expelled  as  near  as  can  be,  they  sometimes  reaccumu- 
late  and  are  again  discharged,  and  repetitions  of  these  processes  lead 
to  still  more  chronic  suffering,  until  the  patient  becomes  a  permanent 
invalid,  or  dies  from  such  long-standing  exhaustion.  We  may,  with 
a  good  deal  of  certainty,  cause  contraction,  granulation,  and  oblitera- 
tion of  the  cavity,  by  injecting  it  with  iodine,  wine,  or  other  irritant. 
The  best  way  to  secure  efficiency  in  injections  is  to  introduce  through 
the  fistulous  opening,  or  one  made  for  the  purpose,  a  small  flexible 
catheter,  so  as  to  reach  the  bottom  of  the  cavity  and  throw  the  fluid 
through  this  tube.  We  thus  place  the  fluid  used  in  full  strength  in 
contact  with  the  walls  of  the  cavity,  while  the  injection  thrown  out  of 
a  common  syringe  will  mix  it  up  with  the  contents  of  the  sac,  and 
thus  dilute  it. 

Chronic  Retrouterine  Hsemotocele. 

1  have  met  with  a  considerable  number  of  hematoceles  that  did  not 
terminate  by  absorption  or  suppuration,  but  remained  in  a  latent 
condition,  sometimes  for  years,  and  then  became  the  subjects  of  change 
in  their  contents  which  rendered  radical  treatment  indispensable. 
In  the  history  of  many  of  these  cases  the  essential  facts  necessary  to 
lead  to  a  rational  diagnosis  are  lost. 


CHROXIC   EETEOUTEEINE    HEMATOCELE.  339 

The  time  when  the  effusion  occurred  is  so  remote  that  many  of  the 
symptoms  have  been  forgotten,  or,  taking  place  contemporaneously 
with  an  abortion,  or  paroxysm  of  dysmenorrhoea,  and  the  symptoms 
of  hsematocele  were  so  blended  with  those  of  the  other  condition  that 
they  escaped  notice.  Not  unfrec|uently  our  attention  is  called  to  these 
cases  for  a  long  time  passing  for  retroversion  of  the  uterus,  in  the 
hands  of  inexperienced  practitioners  wdthout  being  recognized. 

After  a  greater  or  less  length  of  time  some  of  them  undergo  rapid 
increase  of  size,  from  an  accumulation  of  serum,  while  others  grow 
more  slowly,  but  still  become  decidedly  inconvenient  tumors. 

One  of  the  former  kind  has  quite  recently  come  under  my  notice. 
The  patient  was  twenty-four  years  of  age,  the  mother  of  two  children, 
enjoyed  good  health  until  two  years  since,  when  she  had,  wdthout 
any  assignable  cause,  severe  flooding,  and  was  thereafter  confined  to 
bed  for  several  weeks.  She  gradually  recovered  sufficiently  to  very 
poorly  attend  to  her  household  duties.  She  did  not  have  the  advice 
of  an  experienced  practitioner  until  three  or  four  months  before  she 
came  under  my  notice.  Her  j^hysician  at  that  time  discovered  a 
retrouterine  tumor  that  extended  above  the  brirh  of  the  pelvis,  with 
the  most  prominent  elevation  on  the  right  side,  wdiere  it  arose  one 
and  a  half  inches  above  the  pubis.  When  first  observed  the  lower 
portion  of  the  tumor  extended  about  an  inch  below  the  cervix  uteri. 
From  that  time  the  tumor  grew  perceptibly  until,  at  the  time  she 
came  to  me,  the  posterior  cul-de-sac  was  very  tensely  distended.  The 
lower  end  of  the  tumor  was  elastic,  but  too  tense  for  undoubted  fluctu- 
ation. The  upper  part  of  the  tumor  remained  as  above  described. 
Dr.  D.  T.  Nelson  examined  the  patient  on  the  same  day,  Thursday, 
the  24th  of  February,  1881.  We  requested  her  to  call  again  on  the 
27th  of  the  same  month,  or  three  da3's  later.  When  she  came  again 
for  examination  we  were  both  astonished  at  the  rapid  increase  in  size 
manifested  at  the  lower  end  of  the  tumor.  The  lower  end  of  the 
tumor  w^as  so  much  larger,  and  distended  so  far  down  as  to  begin  to 
separate  the  external  labia.  The  question  wdth  us  was  between  a 
fungus  or  malignant  tumor,  behind  and  attached  to  the  uterus,  or  an 
old  hsematocele.  She  was  at  once  admitted  into  the  Woman's  Hos- 
pital, and  the  next  day  a  small  trocar  was  thrust  into  the  tumor  for 
exploratory  purposes. 

A  large  amount  of  reddish  serum  was  ejected  with  great  force 
through  the  canula.  I  then  made  a  small  incision  by  the  side  of  the 
trocar,  through  which  I  introduced  my  finger,  and  enlarged  it  so  that 
I  could  introduce  two  fingers  into  the  cavity.  The  fingers  at  once  en- 
countered large  deposits  of  macerated  fibrin  clinging  to  the  wall  of  the 
cyst.  These  were  separated  as  far  as  practicable,  the  cavity  thoroughly 
washed  out,  and  several  pledgets  of  cotton  saturated  with  tincture  of 


340  METATITHMENIA. 

iron  introduced.  The  serum  contained  albumen  and  the  coloring 
matter  of  blood. 

A  very  remarkable  case,  with  the  commencement  of  which  I  was 
cognizant,  is  recorded  in  the  first  volume  of  the  Transactions  of  the 
American  Gynecological  Society,  by  George  H.  Bixby,  M.D.,  of 
Boston. 

I  saw  the  patient  and  attended  her  for  three  or  four  months  after 
the  effusion  occurred  and  diagnosed  retrouterine  hfematocele.  During 
the  time  I  attended  her  the  tumor  decreased  decidedly,  and  I  fully 
expected  it  to  be  entirely  absorbed.  The  patient,  as  Dr.  Bixby  ob- 
serves, passed  out  of  my  care,  but  remained  in  Chicago,  where  I  could 
know  somewhat  of  her  condition. 

She  was  an  invalid  during  the  whole  seven  years  intervening  be- 
tween my  attendance  and  the  time  she  went  to  Boston.  As  she  was 
leaving  Chicago  for  Boston  she  desired  me  to  make  an  examination. 
The  tumor  was  easily  recognized  at  that  time,  but  was  not  large.  I 
subjoin  Dr.  Bixby's  description  of  the  case  after  she  went  to  Boston: 

"Mrs.  H ,  aged  thirty-nine,  a  resident  of  Boston,  consulted  Dr.  Mack,  of  St. 

Catharine's,  Ontario,  for  an  obscure  pelvic  tumor.  On  the  following  day  I  was  called 
in  consultation.  The  patient  was  of  dark  complexion  and  nervous  temperament. 
Menstruation,  which  first  appeared  at  eighteen  and  recurred  at  intervals  of  three 
weeks,  was  scanty  and  painless.  In  her  youth  she  was  unusually  fond  of  outdoor 
sports,  and  later  in  life  indulged  in  horseback  exercise.  She  was  married  at  twenty- 
one,  and  supposed  she  miscarried  two  years  later.  Seven  years  previously,  while 
under  the  care  of  Professor  Byford  for  uterine  disease,  she  became  the  subject  of  hsema- 
tocele,  but  shortly  after  passed  out  of  his  hands.  For  two  years  Mrs.  H.  had  been 
suffering  from  a  peculiar  pain  in  the  left  ovarian  region,  and  also  from  renal  and 
vesical  derangements.  She  described  the  pain  as  occurring  in  paroxysms,  at  first  light, 
gradually  increasing  in  intensity  until  almost  insupportable,  then  as  gradually  sub- 
siding. Soon  after  the  recurrence  of  the  above  symptoms  her  attention  was  directed 
to  a  tumor  the  size  of  a  small  orange  at  the  seat  of  pain.  In  the  dorsal  position,  with 
the  limbs  flexed,  percussion  gave  evidence  of  a  well-defined  dulness  in  the  left  ovarian 
and  superpubic  regions;  by  bimanual  palpation  unmistakable  fluctuation.  The  uterus 
was  fixed,  and  lateroverted  to  the  right ;  its  cavity  two  and  one-half  inches  in  depth. 
Exploratory  puncture  (through  Douglas's  fossa),  with  a  small  trocar  by  Dr.  Mack, 
confirmed  the  existence  of  fluid.  Three  pints  of  a  light  straw-colored  serum  were 
withdrawn  by  aspiration,  which  completely  emptied  the  cyst.  The  result  of  an  analysis 
by  Dr.  Fitz,  of  Boston,  was  as  follows  :  '  A  clear,  light  reddish-brown,  odorless,  slightly 
alkaline  fluid,  sp.  gr.  1020;  absence  of  sediment ;  abundance  of  albumen,  it  becoming 
solid  by  boiling;  abundant  chlorides  and  sulphates.  Microscope  reveals  numerous 
oil-globules,  a  few  round  cells  with  large  nuclei  and  a  small  amount  of  granular  pro- 
toplasm ;  an  occasional  granular  corpuscle.  If  it  be  a  question  between  ascitic  or 
ovarian,  the  latter  is  probable.'  ZSTothwithstanding  this  result  we  were  disposed  to 
consider  this  case  one  of  encysted  dropsy  of  the  peritoneum  following  hematocele. 
Being  now  intrusted  to  my  care  she  was  ordered  rest  in  bed,  no  treatment.  Not  the 
slightest  reaction  followed  the  operation,  and  in  the  course  of  three  weeks  she  resumed 
her  ordinary  duties. 

"  Dr.  Mack  was  disposed  to  attribute  much  of  the  pain  as  well  as  the  renal  derange- 


DIAGNOSIS.  341 

ment  to  pressure  upon  the  nervous  filaments  of  the  tissues  in  the  vicinity  of  the  cyst. 
The  description  of  the  pain  and  the  renal  and  vesical  symptoms  were  at  least  sugges- 
tive of  some  interference  with  the  functions  of  the  ureter  by  pressure  from  the  cyst. 

"The  following  letter  from  Dr.  Byford,  received  since  the  operation,  tends  to  con- 
firm the  diagnosis: 

"' Deae  Doctor  :  lean  emphatically  indorse  your  diagnosis  and  proposed  treat- 
ment. In  my  own  practice  1  have  met  with  but  two  cases  of  serous  accumulation 
after  hsematocele.  One  was  cured  by  a  single  tapping  with  the  aspirator,  the  other 
by  establishing  a  permanent  drain  from  the  cavity.  In  the  last  case  reaccumulation 
took  place.  I  then  punctured  with  a  large  trocar,  and  passed  through  the  canula 
a  flexible  catheter,  and  left  it  in  position.  The  cure  was  effected  in  about  three 
weeks.' " 

Diagnosis. 

The  diagnosis  of  these  old  hsematoceles  is  not  always  easy.  The 
history,  if  the  patient  can  intelligently  trace  it,  will  often  lead  to  a 
strong  suspicion  of  the  character  of  the  tumor.  The  primary  attack 
may  date  back  several  months,  and  sometimes  as  many  years,  and 
may  have  been  distinguished  by  symptoms  arising  from  the  continued 
presence  and  occasional  augmentation  of  the  tumor,  indicative  of  some 
form  of  pelvic  disease.  Not  unfrequently,  however,  the  commence- 
ment is  so  obscured  by  attendant  circumstances  as  to  evade  the  most 
diligent  inquiry,  when  we  shall  be  obliged  to  depend  upon  recent 
developments  and  physical  examination  for  a  diagnosis. 

In  many  cases  the  patient  will  have  suffered  a  long  time  from  pelvic 
symptoms,  and  be  aware  of  the  existence  of  a  tumor.  The  tumor  is 
often  mistaken  for  growths,  as  ovarian  or  uterine  tumors,  and  even 
extrauterine  pregnancy.  In  hsematocele  the  tumor  is  situated  behind 
and  adherent  to  the  uterus.  The  uterus  is  pressed  strongly  forward 
and  upward,  and  generally  to  the  right  side,  so  that  the  fundus  may 
be  felt  above  the  right  ramus,  itself  simulating  a  tumor.  Generally 
the  top  of  the  hsematocele  may  be  recognized  by  pressing  the  hand 
down  into  the  brim  of  the  pelvis,  while  the  lower  end  will  be  found  to 
fill  up  the  cul-de-sac  of  Douglas,  and  distend  it  very  greatly.  The 
distension  is  especially  downward,  reaching  occasionally  as  low  as  the 
external  organs. 

I  should  regard  the  forcible  downward  distension  of  the  cul-de-sac 
with  fluid  as  a  very  important,  if  not  a  distinctive  sign  of  chronic 
hsematocele.  The  upper  part,  or  fibrinous  covering  of  the  haematocele, 
is  inelastic  and  does  not  permit  of  distension  in  that  direction,  while 
the  wall  of  the  retrouterine  pouch  is  elastic  and  permits  distension. 
An  ovarian  tumor,  a  tumor  of  the  lateral  ligament,  or  an  extrauterine 
pregnancy  develops  upward  instead  of  downward.  While  any  or  all 
of  these  may  be  felt  to  occupy  the  cul-de-sac,  they  do  not  forcibly 
distend  it  downward.  Instead  of  displacing  the  uterus  upward  as 
well  as  forward,  they  displace  it  forward  at  first,  and  afterwards  down- 
ward. 


342  METATITHMENIA. 

The  hardness  and  more  globular  shape  of  a  fibroid  tumor,  situated 
in  the  retrouterine  space,  will  generally  enable  us  to  distinguish  it  from 
an  old  haematocele.  An  abscess  is  seldom  situated  immediately  behind 
the  uterus,  and  when  it  is  there  is  generally  so  much  hardness  around 
the  presenting  fluid  as  to  make  the  distension  irregular,  aside  from  the 
usual  tenderness. 

"When  the  diagnosis  cannot  be  made  in  any  other  way  the  tumor 
may  be  aspirated.  The  fluid  drawn  from  an  old  hfematocele  is  well 
described  in  Dr.  Bixby's  case.  The  coloring  matter  of  the  blood  is 
always  noticeable. 

Treatment. 

The  proper  treatment  of  the  chronic  hffimatocele  consists  in  evacu- 
ating it,  draining  the  cavity,  and  frequent  injections  of  some  disinfec- 
tant solution, — the  carbolic  acid  or  permanganate  of  potash.  When  a 
sufficient  amount  of  fluid  is  removed  for  diagnostic  purposes  the  tro- 
car or  asj^irator  needle  may  be  taken  as  a  guide  for  the  incision.  The 
incision  should  be  made  in  the  most  prominent  part  of  the  tumor  large 
enough  to  admit  the  finger.  The  index  finger  should  be  introduced 
through  it,  and  be  made  to  tear  a  large  opening  into  the  sac.  The 
opening  must  be  large  enough  to  admit  two  fingers  freely  into  the 
cavity.  Large  deposits  of  the  fibrin  of  the  blood  will  be  found  adher- 
ing to  the  inner  wall  of  the  sac.  The  removal  of  these  coagula  of 
fibrin  is  very  important,  for  if  allowed  to  remain  they  will  undergo 
decomposition,  and  thus  be  the  source  of  sepsis.  The  large  opening 
I  have  recommended  has  the  advantage  of  permitting  the  free  use  of 
the,  fingers  for  this  purpose  and  the  efficient  cleansing  of  the  cavity  by 
injections.  When  carefully  performed  this  operation  causes  little  or  no 
shock,  and  the  patient  usually  recovers  in  two  or  three  weeks  from  the 
effects  of  the  evacuation.  It  requires  several  months  for  the  sac  itself 
to  be  removed  by  absorption.  Eventually,  however,  it  disappears  to 
such  an  extent  as  not  to  be  recognizable  by  an  ordinary  vaginal  ex- 
amination, and  with  proper  care  the  patient  speedily  recovers  her 
usual  health. 


CHAPTER    XIV. 

CHANGE  OF  LIFE— MENOPAUSE  AND  SENILITY. 

At  the  period  when  woman  ceases  to  menstruate  various  changes  in 
her  system  occur,  which  constitute  what  is  termed  ''change  of  life." 
The  peculiar  anatomical  feature  noticeable  is  progressive  atrophy  of 
the  ovaries,  uterus,  and  usually  of  all  the  other  female  organs,  in- 
cluding the  mammary  glands. 

Dr.  Tilt,  in  his  excellent  work  on  the  Change  of  Life,  says  :  "  Puberty 
and  the  change  of  life  are  caused  by  anatomical  changes,  the  one  by 
ovarian  evolution,  the  other  by  ovarian  involution."  I  should  say 
these  two  conditions  were  accompanied  by,  instead  of  caused  by,  the 
ovarian  evolution  and  involution. 

The  change  of  life  is  an  important  epoch  in  a  woman's  existence, 
for  if  not,  as  Dr.  Tilt  thinks,  the  cause  of  many  diseases,  it  is  contem- 
poraneous with  a  number  of  the  most  dangerous  affections,  and  cer- 
tainly modifies  very  materially  the  course  of  others.  When  not  ac- 
companied by  disease  it  is  normal,  and  usually  leaves  the  woman,  to  say 
the  least,  in  no  worse  condition  than  before  it  occurred.  Generally  she 
becomes  more  vigorous  after  it,  and  her  prospects  for  life  and  health 
are  increased. 

The  change  of  life  is  gradual,  requiring  from  one  to  eight,  or  even 
ten  years  for  the  processes  of  involution  and  changes  in  all  the  body 
to  take  place.  The  average  of  the  menojjause  is  forty-five  years. 
While  it  may  not  always  be  the  case  I  think  a  very  early  or  very  late 
menopause  is  abnormal  in  other  respects  than  time.  The  cases  that 
come  about  very  early  in  life  are  much  more  frequently  than  otherwise 
caused  by  pathological  conditions.  Peculiarity  of  organization  is  the 
only  way  to  account  for  the  remainder.  Such  instances  as  have  fallen 
under  my  observation  were  without  exception  preceded  by  diseases  of 
the  uterus  and  probably  of  the  ovaries.  I  say  probably,  because  the 
ovarian  affection  cannot  always  be  diagnosticated  with  certainty. 
The  late  menopause  I  have  not  met  with  as  often,  and  I  have  not  been 
so  clearly  convinced  of  the  condition  of  the  patients  as  in  the  former. 
In  such  cases  as  I  have  noticed  most  of  the  women  seemed  to  be  pecu- 
liarly vigorous,  though  sometimes  I  have  thought  the  long-continued 
functional  activity  of  the  genital  system  appeared  to  depend  upon 
chronic  hypergemia,  caused  by  tumors,  congestion,  or  inflammation. 

Simple  cessation  of  the  menstrual  return  is  not  the  change  of  life. 
When  the  menses  cease  from  a  failure  of  the  general  powers,  the  term 
will  not  api^ly. 


344  CHANGE   OF    LIFE — MENOPAUSE    AND    SENILITY. 

The  cessation  of  the  menses  does  not  always  take  place  in  the  same 
way.  Sometimes  it  occurs  suddenly,  with  no  change  in  the  c^uantity, 
quality,  or  jDcriodicity  up  to  the  last  return,  and  with  no  premonitory 
symptoms.  At  other  times  a  change  in  the  periodicity  of  the  men- 
strual flow  occurs  as  a  premonitory  symptom  of  its  cessation,  the  in- 
tervals in  some  cases  being  irregular,  in  others  steadily  decreasing  in 
time  until  complete  cessation  occurs. 

Not  unfrequently  the  menstrual  discharges  grow  progessively  less 
for  ten  or  twelve  years  before  they  completely  cease.  By  this  method 
the  change  of  life  becomes  an  accomplished  fact  only  after  a  compara- 
tively protracted  transitional  ^Deriod.  Sometimes  a  severe  hemorrhage 
is  succeeded  by  the  menopause. 

Numerous  other  methods  exist  by  which  this  important  change  is 
brought  about ;  those  which  I  have  mentioned  are  the  more  common 
ones. 

There  are  probably  no  reliable  symptoms,  not  immediately  connected 
with  the  cessation  of  the  menses,  to  indicate  4:he  approach  or  even  the 
progress  of  the  change  of  life  if  the  woman  is  in  a  perfectly  healthy 
condition.  The  change,  when  a  healthy  one,  is  so  gradual  that  the 
various  organs  and  the  nervous  and  vascular  systems  have  amjDle  time 
to  accommodate  themselves  to  the  difference  in  the  functions  of  the 
sexual  system. 

Does  the  change  of  life  give  origin  to  the  diseases,  or  to  any  of  them, 
occurring  at  that  time  ?  My  opinion  is  that  it  does  not.  I  believe  them 
to  be  merely  coincident.  Fibroid  tumors  of  the  uterus  and  cancer  of 
various  organs  do  frequently  occur  about  the  time  of  the  menopause, 
but  they  also  are  often  met  with  both  before  and  after  that  period. 
The  long  list  of  diseases  and  symptoms  enumerated  by  Dr.  Tilt  are 
only  evidence  that  the  woman  was  diseased  before,  or  became  so  at  the 
time,  from  other  causes,  instead  of  indicating  the  change  of  life  as  the 
cause  of  them. 

Yet  there  is  little  doubt  that  the  progress  of  existing  diseases  is 
modified  by  the  changes  in  the  circulation,  nutrition,  and  nervous 
energies  which  occur  at  the  change  of  life.  In  different  parts  of  the 
present  work  I  have  alluded  to  this  in  describing  the  diseases  in  per- 
sons of  different  ages.  Women  undergoing  the  change  of  life  who  are 
not  the  subject  of  disease  require  no  special  management  or  treatment. 
It  is  well  to  have  them  as  nearly  as  jDOSsible  cured  of  the  inflamma- 
tions, congestions,  and  displacements  which  afflict  them,  as  that  will 
cause  the  j)rocess  to  be  more  easily  and  naturally  accomplished.  How- 
ever, I  think  we  need  not  fear  that  the  change  of  life  will  be  disastrous 
either  as  a  cause  of  disease  or  by  injuriously  modifying  those  already 
existing.  As  elsewhere  stated,  we  usually  expect  chronic  inflamma- 
tion and  its  consequences  to  be  benefited,  if  not  entirely  cured,  by 
senile  involution  of  the  organs  of  generation,  and  we  also  often  find 


CHANGE    OF    LIFE MENOPAUSE    AND    SENILITY.  345 

the  fibroid  degeneration  and  growths  of  the  uterus  arrested  in  their 
progress  by  the  same  change.  In  all  respects,  when  not  complicated, 
we  may  expect  the  menopause  to  be  a  favorable  crisis  in  woman's  life; 
and  even  when  contemporaneous  with  diseases,  it  is  much  more  likely 
to  beneficially  influence  their  course  than  cause  them  to  be  aggravated. 
In  all  my  expressions  on  the  subject  I  have  steadily  kept  in  mind  the 
fact  that  the  menopause  is  but  an  incident  among  the  processes  which 
go  to  constitute  the  change  of  life.  Senility  in  woman,  after  a  com- 
plete change  of  life,  is  a  state  in  which  she  is  free  from  the  embarass- 
ments  connected  with  the  active  sympathies  of  the  genital  organs. 
Her  diseases  are  more  simple  and  less  liable  to  become  complicated. 
They  are  no  longer  female  in  their  nature  but  fall  into  the  category  of 
common  diseases.  Exceptions  occur  to  this  statement.  We  do,  though 
rarely,  find  some  of  the  diseases,  such  as  metritis,  and  even  ovaritis, 
etc.,  commencing  in  old  age.  When  they  do  originate  in  this  stage  of 
life,  as  the  genital  organs  are  in  a  state  of  feeble  vitality,  and  the  gen- 
eral system  is  incapable  of  exerting  the  same  recuperative  force  as  in 
earlier  life,  we  may  expect  them  to  be  both  more  obstinate  in  their  re- 
sistance to  treatment  and  more  disastrous  in  their  course. 


CHAPTER    XV. 

ACUTE  INFLAMMATION  OF  THE  UNIMPKEGNATED  UTERUS. 

Causes. 

Acute  inflammation,  not  arising  from  specific  causes,  generally 
affects  the  fibrous  portion  or  substance  of  the  walls  of  the  uterus.  It 
almost  always,  if  not  quite,  pervades  the  whole  of  the  organ,  the 
fundus,  body,  and  cervix.  Exposure  to  cold  is  the  most  frequent 
cause.  The  cold  may  be  applied  to  the  general  surface  when  the 
uterus  is  in  a  state  of  turgescence  from  menstrual  congestion,  sexual 
excitement,  or  incomplete  involution  after  labor  or  abortion.  The 
same  agent  acting  upon  a  portion  of  the  surface,  as  the  feet  and  legs, 
under  a  similar  condition  of  the  organ,  may  give  rise  to  the  same  dis- 
ease. It  is  not  likely  that  cold,  however  applied,  would  be  a  sufficient 
cause,  but  for  the  predisposing  condition  I  have  mentioned.  The  ex- 
citement of  excessive  sexual  indulgence  may  be  carried  so  far  as  to 
cause  a  moderately  acute  inflammation  of  the  substance  of  the  uterus, 
as  also  blows  upon  the  abdomen,  etc. 

It  is  not  a  very  common  disease,  and  yet  I  do  not  think  it  can  be 
regarded  as  an  infrequent  affection. 

Symptoms. 

In  speaking  of  the  symptoms  of  the  disease,  I  wish  the  reader  to 
bear  in  mind  that  their  intensity  will  vary  from  a  mildness  that  will 
scarcely  confine  the  patient  to  her  couch  to  a  very  severe  and  grave 
disease,  almost  overwhelming  the  nervous  system,  with  delirium  and 
convulsions,  and  calling  the  stomach  into  excruciating  symjjathy  with 
it.  In  considering  the  subject,  I  wish  to  be  understood  as  attaching 
more  importance  to  the  suddenness  than  to  the  intensity  of  the  attack 
in  determining  the  nomenclature. 

It  is  somewhat  owing  to  the  exciting  cause,  as  to  the  symptom 
which  is  likely  to  usher  in  the  attack.  If  the  cause  is  a  moderate 
one,  as  excessive  sexual  indulgence,  pain  will  generally  begin  some 
time  before  the  general  symptoms.  If  the  cause  is  cold  suddenly 
and  extensively  apiDlied  to  a  menstruating  patient,  chills  and  rigors 
may  precede  the  pain.  However  that  may  be,  when  the  case  is  fairly 
developed  there  is  fever,  aching  in  the  back,  pain  in  the  head  and  ex- 
tremities, flushed  face,  and  furred  tongue.  In  addition  to  these  general 
manifestations  there  is  local  pain,  indicating  the  organ  affected.  This 
pain  may  be  confined  almost  entirely  to  the  sacrum  and  the  lumbar 


PROGjSTOSIS — DIAGNOSIS.  347 

region  if  the  inflammation  is  moderate,  but  generally  there  is  pain  in 
the  pelvis  behind  the  pubis,  or  in  one  or  both  iliac  regions.  Some- 
times the  pain  radiates  in  several  directions  up  the  abdomen,  down 
the  thighs,  and  around  the  body.  The  pain  is  usually  of  a  dull 
aching,  but  sometimes  of  a  sharp  character.  In  addition  to  these 
symptoms  indicating  inflammation  in  some  of  the  pelvic  organs,  the 
nervous  system  is  often  afiFected  with  hysterical  symptoms,  convul- 
sions, coma,  laughing,  crying,  or  unreasonableness  of  some  kind.  I 
should  have  mentioned  among  the  local  symptoms  dysuria  and  diffi- 
cult and  painful  defecation.  Should  the  peritoneal  covering  become 
involved  there  is  swelling  and  greater  or  less  tenderness  of  the  abdo- 
men.    Nausea  and  even  vomiting  are  not  infrequent  symptoms. 

After  a  week  or  more  of  this  kind  of  suff"ering  the  symptoms  gradu- 
ally subside,  and  the  patient  slowly  recovers  her  usual  health ;  or 
sometimes  the  subsidence  of  the  pains  is  not  complete,  and  she  con- 
tinues to  suffer  with  a  chronic  form  of  inflammation.  The  termina- 
tion is  almost  ahvays  in  resolution  or  the  chronic  form  of  the  disease. 
Possibly,  in  some  exceedingly  rare  instances,  the  force  of  inflammation 
is  spent  in  some  circumscribed  locality,  and  it  proceeds  to  suppura- 
tion. I  have  lately  seen  an  instance  of  this  kind  where  the  suppura- 
tion was  in  the  anterior  lip  of  the  cervix. 

Prognosis. 

■  The  termination  is  so  frequently  in  resolution  or  a  moderate  form 
of  chronic  inflammation,  that  we  may  almost  always  expect  complete 
or  partial  recovery.  Death  probably  never  results  in  uncomplicated 
cases  of  acute  metritis,  but  unfortunately  we  occasionally^  meet  with 
grave  and  even  fatal  peritonitis,  apparently  resulting  from  extension  of 
the  disease  from  the  uterus.  It  has  been  my  misfortune  to  have  lately 
met,  in  consultation,  with  two  instances  of'  this  sort.  Although  the 
prognosis  is  favorable,  as  a  general  rule,  so  far  as  the  recovery  of  the 
patient  from  the  attack  is  concerned,  it  is  not  so  favorable  for  the 
complete  re-establishment  of  health,  as  the  patient  is  likely  to  be 
affected  with  chronic  inflammation  in  the  body  or  cervix.  Not  un- 
frequently  we  trace  chronic  inflammation  back  to  a  moderate  attack 
of  the  acute. 

Diagnosis. 

Inflammation  of  the  cellular  tissue  beside  the  uterus,  metatithmenia, 
rectitis,  or  cystitis,  cause  symptoms  which  may  be  mistaken  for  me- 
tritis. When  doubt  exists  it  may  be  easily  and  certainly  solved  by  a 
digital  examination.  If  the  bladder  is  the  seat  of  disease,  the  tender- 
ness complained  of  by  pressing  it  between  fingers  in  the  vagina  and 
others  above  the  pubis  will  be  sufficient  proof;  pressure  may  be  made 
upon  the  rectum  by  including  it  between  the  introduced  fingers  and 


348      ACUTE   INFLAMMATION   OF   THE   UNIMPREGNATED   UTERUS. 

the  sacrum.  The  inflammation  at  the  side  of  the  uterus,  or  cellulitis, 
causes  tenderness  and  hardness  close  to  the  iliac  bones  on  the  side, 
and  the  hardness  seems  to  be  continuous  with  the  bones.  The 
greatest  tenderness  is  therefore  close  to  the  side  of  the  pelvis.  In  all 
these  cases  the  uterus  may  be  touched,  provided  it  is  not  moved  so 
as  to  press  upon  the  inflamed  part  or  organ  without  causing  pain. 
If  it  is  the  seat  of  inflammation  the  tenderness  will  be  confined  to 
that  organ,  while  all  the  rest  are  free  from  it,  and  may  be  handled 
freely.  We  should  not  forget  that  all  these  organs  may  be  implicated 
in  one  great  mass  of  acute  inflammation,  and  all  the  pelvic  contents 
be  intolerably  tender  to  the  touch.  In  an  examination  to  diagnosti- 
cate inflammation  of  the  uterus,  I  need  hardly  say  that  a  resort  to 
instruments  is  unnecessary. 

Treatment. 

The  intensity  of  the  inflammation  will  govern  us  in  the  activity  of 
treatment.  If  it  is  not  attended  with  great  pain  or  febrile  reaction, 
although  our  remedies  must  be  the  same,  there  is  no  need  of  using 
them  with  the  same  energy.  We  should,  however,  bear  in  mind  the 
great  likelihood  of  leaving  the  chronic  form  behind,  and  be  diligent 
in  our  medicinal  and  hygienic  appliances  when  practicable,  until 
every  vestige  is  gone.  If  the  attack  is  moderate,  it  may  sometimes  be 
interrupted  in  the  beginning,  by  measures  to  induce  a  copious  per- 
spiration, more  particularly  if  caused  by  an  exposure  to  cold.  Even 
a  smart  attack  may  sometimes  be  relieved  by  a  large  dose  of  opium 
and  a  steam-bath,  used  within  a  few  hours  after  the  commencement 
of  the  symptoms.  After  the  symptoms  have  become  fairly  established 
and  have  lasted  for  twenty-four  hours,  we  must  not  expect  to  find  im- 
mediate relief,  and  should  begin  the  systematic  use  of  antiphlogistic 
treatment.  In  the  subacute  form,  a  brisk  cathartic,  foot-bath,  and 
fomentations  over  the  uterus,  should  be  followed  by  tart,  antimony, 
muriate  of  ammonia,  and  calomel. 

Perfect  quietude  should  be  enjoined  also,  and  rest  at  night  may 
be  insured  by  giving  one  grain  of  calomel,  with  twice  the  amount 
of  opium,  in  a  pill  at  bedtime.  Continued  for  five  or  six  days  this 
will  generally  induce  slight  mercurial  effect,  when  the  pain  and  other 
symptoms  will  pretty  surely  subside.  If  they  do  not  do  so,  a  blister 
over  or  a  little  above  the  pubis  will  aid  in  banishing  them.  If  the 
attack  is  severe,  we  ought  to  add  to  the  above  remedies  the  more 
immediately  deiDressing.  The  patient  may  be  bled  from  the  arm 
until  a  decided  impression  upon  the  pulse  is  produced,  or  we  may 
apply  from  ten  to  twenty  leeches  to  the  vulva  and  groins,  as  a  de- 
pletory measure.  In  the  country,  where  leeches  cannot  be  had,  scari- 
fication and  cupping  can  be  profitably  substituted  for  them.  Should 
arterial  excitement  be  high  after  the  depletory  measure,  the  tinct.  of 


ACUTE   INFLAMMATION   OF   MUCOUS   MEMBRANE   OF   UTERUS.      349 

verat,  viride  in  doses  from  four  to  six  drops  every  four  hours,  with 
the  ammon.  mixture,  will  be  an  efficient  adjunct  to  our  remedial 
measures.  The  calomel  should  be  withheld  as  soon  as  its  specific 
effects  are  produced. 

I  should  not  discharge  the  obligation  I  feel  to  the  student  in  the 
treatment  of  this  disease  were  1  not  again  to  caution  him  against  an 
imperfect  cure  of  it.  Very  often  it  becomes  chronic,  and  renders  the 
patient  miserable  for  years.  We  should  try  to  avoid  this  consequence. 
Too  early  a  resumption  of  duties  and  active  exercise  should  be  espe- 
cially prevented.  When  practicable,  a  continuation  of  treatment  and 
avoidance  of  the  causes  which  produced  the  inflammation  are  of 
equal  importance.  As  a  means  of  perfecting  the  cure  which  the  more 
active  treatment  has  brought  about,  the  sedative  effect  of  water  affords 
us  valuable  aid.  The  sitz-bath  and  vaginal  injections  are  the  modes 
of  using  it.  The  sitz-bath  ought  to  be  used  as  much  as  the  time  and 
patience  of  the  patient  can  be  made  to  allow.  An  hour  is  short 
enough  time,  and  two  hours  is  better,  twice  or  thrice  in  twenty-four 
hours.  The  injections  should  be  copious,  and  may  be  used  in  the 
bath  and  of  the  same  water.  From  two  to  four  gallons  of  water  ought 
to  be  passed  through  the  vagina  in  this  way  each  time  the  bath  is  used, 
by  means  of  the  rubber  syringe. 

Acute  Inflammation  of  the  Mucous  Membrane  of  the  Uterus. — I  do  not 
know  that  I  have  ever  met  with  an  uncomplicated  case  of  acute  in- 
flammation of  the  mucous  membrane  of  the  uterus.  Cases  that  I 
have  seen  have  been  connected  v/ith  inflammation  of  the  vagina,  and 
have  arisen  as  the  effect  of  some  poison  directly  applied  to  the  mem- 
brane. Most  of  them  were  gonorrhoeal,  but  in  some  I  have  been 
puzzled  to  determine  whether  the  poison  of  this  affection  was  the 
cause  or  not.  Probably  this  poison  gets  into  families,  where  and  in 
^Yays  it  ought  not,  and  thus  deceives  us.  However  this  may  be,  I 
think  one  of  the  worst  features  of  gonorrhoeal  inflammation  is  the 
frequency  with  which  it  invades  the  mucous  membrane  of  the  uterus 
and  the  difficulty  of  completely  eradicating  it.  It  is  very  apt  to  lurk 
in  the  uterus  after  the  acute  symptoms  are  removed  and  the  inflam- 
mation gone  entirely  from  the  vagina,  and  thus  require  treatment  as 
chronic  endometritis. 


CHAPTEE   XVI. 

GENERAL  CONSIDERATION  ON  "UTERINE  DISEASE"  OR 
HYSTEROPATHY. 

There  is  a  long  list  of  symptoms,  called  nervous,  or  sympathetic, 
which,  although  not  exclusively  confined  to  women,  are  more  fre- 
quently found  to  manifest  themselves  in  them.  They  were  formerly 
regarded  either  as  independent  affections,  or  as  having  various  sources 
of  origin ;  and  although  hysterical  was  the  term  usually  applied  to 
them,  it  was  not  definitely  known  in  what  manner  they  originated. 
Patient  investigation  has  given  us  more  definite  and  correct  notions 
of  them,  and  we  have  come  to  regard  them  as  nearly  always  dei3end- 
ent  on  trouble  of  some  kind  in  the  sexual  system.  Medical  men, 
however,  are  not  united  in  the  opinion  that  the  symptoms  alluded  to 
are  thus  caused,  but  are  divided  into  two  well-defined  parties  with 
respect  to  uterine  pathology. 

1st.  There  are  those  who  believe  that  the  uterus  has  very  little  sym- 
pathetic influence  on  the  system ;  that  the  diseases  of  that  organ  are 
more  frequently  the  result  of  diseases  in  other  organs  than  of  inde- 
pendent origin ;  that  the  symptoms  accompanying  and  almost  always 
found  in  connection  with  actual  lesion  of  the  uterus  do  not  at  all  de- 
pend upon  this  organ ;  that  these  symptoms  may  be  cured  without 
any  attention  to  the  condition  of  the  uterus,  and,  in  fact,  whatever  cures 
them,  almost  always  cures  the  affections  of  that  organ. 

2d.  The  other  party  holds  the  opinion  that  the  sexual  system  of  the 
female,  in  a  state  of  disease,  exercises  a  morbid  influence  over  nearly 
the  whole  organization ;  that  this  morbid  influence  is  particularly  ex- 
erted over  the  spinal  and  cerebral  nervous  systems ;  and  that  the  only 
sure  and  permanent  relief  is  found  in  the  cure  of  the  disordered  con- 
dition of  the  uterus. 

Those  who  adhere  to  the  latter  view  may  be  classified  under  two 
subdivisions,  one  of  which  holds  that  the  sympathetic  influence  of  the 
uterus  is  only  manifested  when  that  organ  is  inflamed  or  ulcerated, 
and  that  the  cure  of  the  inflammation  and  ulceration  relieves  the 
symptoms.  The  other  maintains  that  inflammation  and  ulceration 
are  only  of  slight,  if  indeed  of  an}^,  importance ;  while  the  cause  of  all 
the  difficulty  is  some  sort  of  displacement. 

It  will  probably  surprise  the  student  when  he  is  told  that  all  of  these 
diverse  and  various  oj^inions  are  held  by  gynecologists  of  equal  emi- 
nence, integrity,  and  opportunity  for  observation.  There  is  reason 
for  surprise  in  this  consideration,  and  yet  this  same  diversity  of  opinion 


"uterine  disease"  or  hysteropathy.  351 

exists  in  all  departments  of  medicine ;  for  example,  as  to  the  nature 
and  treatment  of  inflammation,  as  to  the  essential  nature  of  typhoid 
fever  and  its  treatment,  as  to  the  local  or  general  origin  of  cancer,  and 
the  propriety  of  extirpation.  How  can  this  discrepancy  be  accounted 
for?  It  is  not  my  purpose  to  answer  this  question  at  length,  but 
merely  to  indicate  a  few  obvious  considerations,  of  which  one  is  that 
the  attention  of  medical  men  has  been  too  recently  directed  with  suf- 
ficient intensity  to  the  points  involved  to  enable  them  to  make  an 
induction  full  enough  to  convince  by  its  results  all  the  members  of 
the  profession  of  the  correctness  of  any  one  view.  This,  therefore,  is 
just  the  time  when  we  meet  with  conservatism  in  the  views  of  tem- 
perate and  judicious  investigators,  as  well  as  with  the  less  laudable 
conservatism  of  those  who  have  lived  too  long  to  improve.  Another 
consideration  is,  that  while  judicious  practitioners  hold  antagonistic 
opinions  as  to  the  nature  of  diseases,  they  pursue  so  nearly  the  same 
line  of  j)ractice  as  to  lead  to  similar  results  in  the  treatment  of  them. 
A  third  consideration  relates  to  the  power  of  prejudice,  which  forms 
in  very  many  minds  an  invincible  barrier  against  the  acquisition  of 
truth ;  and  the  opinions  imbibed  in  early  education  are  those  which 
are  maintained  the  most  persistently,  sometimes  in  consequence  of  an 
unwillingness  to  learn,  and  sometimes  even  against  the  I'ight  of  reason 
itself.  From  the  pernicious  influences  of  association  and  prejudice 
neither  learned  nor  unlearned  are  exempt. 


CHAPTER    XVII. 

SYMPATHETIC  OR  REFLEX  SYMPTOMS  OF  UTERINE  DISEASE. 

Dr.  Scanzoni*  says  :  "  The  sympathetic  phenomena  which  very 
distant  organs  so  often  present  during  the  course  of  uterine  diseases 
are  of  the  highest  scientific  importance."  They  are  the  more  impor- 
tant because  our  attention  is  more  frequently  called  to  them  than  to 
their  original  exciting  cause.  The  secondary  or  sympathetic  diseases 
often  distress  patients  most,  and  the  fact  of  their  mentioning  no  other 
troubles  may,  without  inquiry,  mislead  us  into  the  opinion  that  they 
are  indej)endent  affections. 

The  general  symptoms  attendant  upon  uterine  disease  are  primarily 
sympathetic  and  secondarily  neurasthenic.  The  sympathetic  are  re- 
flex. An  imj)ression  is  produced  on  the  ganglia  of  that  portion  of  the 
sympathetic  nervous  system  connected  with  the  uterus  and  ovaries 
especially.  Thus  propagated  it  is  conveyed  along  the  nerve  fibrillse 
to  the  genito-spinal  centre,  and  from  this  reflected  to  all  the  organs 
with  which  the  genital  system  is  in  sympathetic  relation. 

The  stomach  is  deranged  in  various  ways ;  the  bowels,  the  liver,  and 
the  spinal  and  cerebral  nerve  centres  become  affected.  The  derange- 
ments of  digestion  interfere  with  nutrition,  the  blood  becomes  poor  in 
the  materials  calculated  to  sustain  the  vigor  of  the  nerve  centres ;  they 
become  ansemic,  and  in  this  way  nervous  exhaustion  occurs  and  we 
have  with  the  original  sympathetic  symptoms,  or  succeeding  them, 
neurasthenia. 

Neurological  writers,  among  whom  are  Drs.  Weir  Mitchell,  Beard, 
and  Professor  Jewell,  ascribe  neurasthenia  to  an  exhausted  state  of  the 
nerve  centres.  If  I  rightly  understand  what  they  mean  by  this  it  is 
that  the  brain  and  spinal  cord  have  become  damaged  by  overaction. 
I  do  not  mean  by  damage,  structural  lesion,  but  a  condition  in  which 
the  cell  action  is  slow,  labored,  and  painful,  because  the  parts  have 
been  overworked,  and  according  to  this  method  of  interpreting  the 
symptoms  they  prescribe  rest  as  one  of  the  essential  jjarts  of  the  cure. 
This  is  so  different  from  the  way  I  look  at  the  subject  that  I  will  risk 
a  concise  statement  of  my  views. 

I  think  that  the  nerve  centres  do  not  become  exhausted,  but  that 
the  blood  circulating  through  them  does  become  exhausted  of  the  ma- 
terial necessary  to  promptly  renew  the  loss  during  functional  action 
of  the  nerve  centres.     On  account  of  the  Avant  of  general  vigor,  the 

*  Diseases  of  Females. 


SYMPATHY   OF   THE   STOMACH.  353 

heart  and  arteries  may  not  transmit  the  blood  through  them  in  the 
usual  quantity,  but  if  the  circulation  is  not  deficient  in  quantity,  the 
blood  itself  is  deficient  in  quality.  With  a  deficient  supply  of  nutri- 
tive material  their  functions  are  performed  irregularly  and  imperfectly, 
and  there  is  neurasthenia. 

If  my  explanation  of  the  origin  of  neurasthenia  is  correct,  absolute 
rest  is  not  so  important  to  the  cure  as  full  feeding. 

We  shall  be  able  to  study  the  general  symptoms  of  uterine  disease 
more  profitably  by  taking  them  up  separately  as  they  are  manifested 
by  different  organs,  and  without  attempting  absolute  correctness  in  this 
respect,  it  will  be  practicable  to  present  them  in  something  like  the 
order  of  frequency  in  which  they  occur. 

Sympathy  of  the  Stomach. 

The  stomach  is  apt  to  be  disturbed  as  early  and  as  frequently  as  any 
other  organ  by  uterine  disease.  This  is  no  more  than  we  would  ex- 
pect, considering  how  often  and  intensely  it  is  influenced  by  preg- 
nancy, and  its  great  readiness  to  complication  in  most  affections  of 
other  parts  of  the  system.  Simple  anorexia  is  one  of  the  most  com- 
mon of  the  sympathies  of  the  stomach,  as  is  also  its  contrary,  vo- 
racity ;  but  occasional  unbecoming,  and  even  disgusting,  depravity  of 
appetite  is  also  met  with.  Inappetency  sometimes  proceeds  to  the 
extent  of  loathing  of  food  and  to  longing  for  inappropriate  articles  of 
diet.  Nausea,  with  loathing  of  food  and  disgust  at  the  smell  of  it,  is 
another  feature  of  stomach  trouble ;  also  frequent  vomiting  when  the 
stomach  is  full;  an  absence  of  discomfort  when  it  is  empty,  and  the 
vomiting  is  sometimes  worse  when  there  are  no  ingesta,  and  nothing 
is  expelled  but  some  of  its  secretions,  which  are  usually  acid,  but 
sometimes  bilious.  Gastralgia  may  occur  when  the  stomach  is  empty ; 
or  during  digestion,  or  immediately  after  swallowing  food.  The  ca- 
pacity of  the  stomach  to  digest  food  of  any  kind  is  often  impaired, 
but  more  frequently  some  particular  sort  of  food  disagrees  with  and 
embarrasses  digestion ;  in  short,  almost  every  form  of  disordered 
stomach  may  be  looked  for  as  the  result  of  the  sympathetic  influence 
of  diseases  of  the  uterus  upon  that  organ.  The  grade  of  functional 
disturbance  may  vary  from  the  slightest  inconvenience  to  that  com- 
plete arrest  of  digestion  which  rapidly  induces  inanition  and  death. 
Extreme  cases  of  indigestion,  however,  are  not  of  frequent  occurrence, 
and  the  disturbances  are  rather  those  of  great  annoyance  than  such 
as  result  in  very  serious  impairment  of  nutrition ;  and  many  patients 
who  constantly  complain  of  suflering  very  severely  from  sensitiveness 
connected  with  digestion  attain  to  a  state  of  apparent  robust  embon- 
point. 

23 


354      SYMPATHETIC   OR   REFLEX    SYMPTOMS    OF    UTEEINE    DISEASE. 

Sympnthetic  Disease  of  the  Boivels. 

The  bowels  probably  sympathize  in  diseases  of  the  uterus  next  in 
frequency  to  the  stomach,  and  their  functional  derangements  are  mul- 
titudinous. ConstiiDation  is  very  common.  The  bowels,  in  many  in- 
stances, have  apparently  no  natural  tendency  to  move.  I  have  one 
patient  who  assures  me  that  she  has  often  been  fourteen  days  without 
any  fecal  discharge  whatever,  and  that  she  dare  not  try  how  long  she 
could  go  without  it,  but  says  that  she  always  uses  some  means  to  pro- 
mote the  alvine  evacuations.  In  other  cases  constipation  terminates 
with  diarrhoea,  and  an  alternation. of  diarrhoea  and  costiveness,  which 
lasts  from  two  to  six  days,  is  a  constant  and  habitual  state  with  the 
patient.  In  cases  of  constipation  resulting  from  this  cause,  the  con- 
stipation seems  to  depend  upon  a  want  of  muscular  tone  in  the  intes- 
tines ;  peristaltic  action  is  deficient,  and  the  appearance  of  the  evacu- 
tions  is  in  all  respects  natural,  and  their  consistence  proper.  In  other 
cases  the  secretions  are  deficient,  and  the  stools  are  dry,  hard,  and 
small  in  quantity.  But  constant  diarrhoea  and  irritable  bowels  are 
also  frequent  accompaniments  of  uterine  disease.  The  passages  may 
be  profuse,  water}^,  and  exhausting,  or  profuse  and  fecal.  A  peculiar 
kind  of  discharge  in  cases  of  diarrhoea  in  uterine  disease  presents  a 
muco-fibrinous  cast  of  the  intestines.  The  casts  are  sometimes  quite 
tenacious  and  of  variable  length,  from  two  to  ten  inches,  and  are  often 
complete  casts  of  the  intestinal  tube ;  at  other  times  there  are  shreds 
of  false  membrane  of  irregular  shape  and  size.  The  discharge  of 
these  substances  is  usually  attended  with  some  dysenteric  symptoms. 
The  diarrhoea  sometimes  seems  to  be  excited  or  aggravated  by  certain 
articles  of  food  ;  at  other  times  one  kind  of  ingesta  seems  to  agree  as 
well  as  another;  and,  again,  the  bowels  may  be  quite  regular,  except 
at  or  near  the  period  of  menstruation.  The  irregularity  is  often  en- 
tirely confined  to  that  time.  With  or  without  diarrhoea  there  may  be 
tumultuous  gaseous  commotion  in  the  bowels  ;  they  may  be  more  or 
less  distended,  or  without  distension  there  may  be  annoj- ing  borboryg- 
mus  and  motion,  from  the  gas  passing  from  one  part  of  the  intestines 
to  another,  inducing  the  opinion  that  pregnane}^  exists.  The  gaseous 
distension  of  the  abdomen  is  sometimes  so  extensive  and  permanent 
as  to  induce  the  overwilling  patient  to  believe  that  it  is  caused  by  ges- 
tation, and  being  frequently  connected  with  hysterical  craftiness,  she 
may  impose  the  same  belief  on  a  careless  practitioner. 

Sympathetic  Affection  of  the  Liver. 

Closely  connected  with  and,  of  course,  very  much  influencing  the 
condition  of  the  alimentary  canal,  is  the  condition  of  the  liver. 
Sometimes  the  bile  is  poured  out  in  such  copious  quantities  as  to 
induce  full  and  free  discharges  of  it  from  the  stomach  by  vomiting, 


SYMPATHETIC    AFFECTIONS    OF   THE    NERVOUS    SYSTEM.        355 

and  to  stimulate  the  intestines  to  copious  bilious  diarrhoea  when  they 
are  not  irritable,  but  subject  to  the  ordinary  stimulation  of  ingesta. 
This  overflow  of  bile  comes  in  paroxysms,  and  produces  a  sort  of 
cholera  morbus.  When  it  occurs  only  once  a  month,  it  is  apt  to  be 
near  the  time  of  menstruation,  or  it  may  return  several  times  between 
the  monthly  periods.  But  there  is  often  a  persistent  absence  of  secre- 
tion for  a  time,  or  this  condition  may  alternate  with  the  other;  or 
the  bile,  instead  of  finding  its  way  into  the  alimentary  canal,  may 
pass  into  the  circulation  and  give  the  skin  a  jaundiced  hue.  When 
the  functions  of  the  liver  are  seriously  disturbed,  there  is  apt  to  be 
at  one  time  a  deficiency  of  bile,  and  at  another  a  great  redundancy. 
I  have  not  seen  this  organ  congested  to  any  great  extent,  as  observed 
by  Dr.  Bennett.  But  I  have  seen  an  enlargement  of  the  spleen  in 
such  instances,  though  I  have  not  supposed  it  to  be  the  result  of  the 
influence  of  uterine  disease.  When  copious  effusions  of  bile  take 
place  somewhat  suddenly,  all  the  pain  and  spasmodic  action  observed 
in  bilious  colic  are  likely  to  present  themselves. 

Sympathetic  Affections  of  the  Nervous  System. 

Much  more  distressing  if  not  more  serious  sufl"ering  is  experienced 
in  the  nervous  system  than  in  the  digestive  apparatus.  Aches,  pains, 
and  complaints  of  evident  nervous  ailments  are  the  peculiar  province 
of  uterine  disease.  There  is  hardly  a  disagreeable  or  even  excruciat- 
ing sensation  that  these  patients  do  not  experience ;  and  too  often 
this  real  suffering  is  mistaken  by  the  friends  for  imaginary,  and  the 
patient's  complaints  are  treated  with  unreasonable  impatience  and 
rudeness  by  persons  from  whom  she  ought  to  receive  kindness  and 
sympathy,  because  her  appearance  does  not  correspond  with  her  mor- 
bid sensations,  as  we  are  apt  to  observe  them  in  other  examples  of 
disease.  It  is  remarkable,  too,  and  a  fact  that  often  impeaches  them 
with  insincerity  in  their  complaints, — when  the  uninitiated  are  the 
judges, — that  these  patients  will  pass  from  a  state  of  excruciating 
suffering  and  loud  complaints,  under  a  little  excitement,  to  one  of 
actual  enjoyment  and  hilarity,  or  conversely.  The  ■  transition  from 
the  excitement  of  private  company,  or  a  public  party,  gives  way  in 
a  few  minutes  to  a  doleful  condition  of  suffering  and  unappeasable 
complaints.  The  inconsistency  of  the  complaints  and  enjoyments, 
the  incapacities  and  the  performances  of  these  patients,  are  almost 
characteristic, — at  least  in  their  sudden  alternation, — and  are  inex- 
plicable in  any  other  way  than  by  supposing  that  the  pains  in  the 
different  organs,  to  which  they  are  referred,  are  more  dependent  upon 
the  general  nervous  susceptibility  than  upon  the  organic  disease  of 
even  trivial  character.  They  are  strictly  neuralgic  in  their  nature, 
and  confined  to  the  nerve-matter  or  tissue  of  the  parts.    A  great  num- 


356      SYMPATHETIC    OR   EEFLEX   SYMPTOMS   OF    UTEEIXE   DISEASE. 

ber  of  the  disagreeable  sensations  and  pains  appear  more  frequently 
in  particular  parts,  and  hence  may  be  distinctly  referred  to  in  this 
description. 

Accompanying  Manifestations  of  Moral  and  Tatellectucd  Perverseness. 

During  the  spasmodic  action  -which,  in  the  majority  of  cases,  has 
to  a  critical  observer  the  appearance  of  being  partly  voluntary,  there 
is  &]}t  to  be  a  singular  perverseness  of  moral  and  intellectual  mani- 
festations, which  was  on  a  certain  occasion  very  graphically  expressed 
by  a  clerical  friend  in  speaking  of  a  patient,  by  saying  that  she 
"  seemed  to  be  actuated  by  an  evil  spirit."  In  the  midst  of  great 
suffering,  patients  not  unfrequently  try  to  bite  and  otherwise  wound 
those  who  endeavor  to  restrain  their  violent  agitation ;  they  attempt 
to  throw  the  covering  from  them  with  the  apparent  object  of  expos- 
ing their  person,  or  say  some  very  perverse  things.  At  other  times 
they  attempt  to  imitate  the  symiDtoms  of  some  grave  organic  affection. 
One  patient,  by  heaving  up  the  lower  part  of  the  chest  spasmodically 
at  rapidly  succeeding  intervals,  induced  her  friends  to  think  that  she 
had  violent  palpitations  of  the  heart,  and  therefore  must  be  the  sub- 
ject of  cardiac  disease;  she  also  imitated  throbbing  of  the  temples  by 
spasmodic  contractions  of  the  temporal  muscle.  "When  this  throbbing 
of  the  temples  was  very  violent,  I  requested  her  to  hold  her  mouth 
open  so  as  to  relax  those  fibres,  but  she  looked  up  and  said  very 
wicked  things,  and  became  contemptuously  calm.  A  request  to  hold 
her  breath  when  the  palpitations  were  violent,  induced  her  to  act  in  the 
same  way,  and  caused  an  instantaneous  cessation  of  them.  The  great 
peculiarity  in  these  spasms  has  always  seemed  to  me  to  be  a  guarded 
cunning,  a  deceitful  and  perverted  consciousness.  To  a  close  observer 
this  is  always  easily  detected.  By  using  the  foregoing  epithets  descrip- 
tive of  the  peculiarity  of  this  kind  of  hysterical  phenomena,  I  do  not 
wish  to  be  understood  as  saying  that  deceit,  cunning,  etc.,  are  indica- 
tions of  freedom  from  disease  on  the  part  of  patients  who  are  thus 
affected.  I  think  this  is  not  usually  the  case,  but  that  they  are  the 
result  of  the  morbid  state  of  the  mind  and  body.  The  spasmodic 
action  of  the  muscles  is  not  contemporaneous  in  the  corresponding 
extremities,  as  in  epileptiform  hysteria  or  epilepsy,  but  is  so  irregular 
as  to  move  the  body  in  many  different  directions  instead  of  giving  to  it 
frequently  repeated  similar  motions. 

Syncopal  Convidsions — Hystero-Epdepsy. 

There  is  a  singular  variety  of  semi-convulsions,  or  syncopal  con- 
vulsions, which  I  have  often  noticed,  and  I  do  not  remember  to  have 
observed  in  any  other  connection.  They  occur  very  frequently  after 
they  have  once  seized  the  patient,  as  often  as  three  or  even  six  or  eight 


MORAL  AND  MENTAL  DEEANGEMENT.  357 

times  during  the  twenty-four  hours.  They  take  place  in  the  daytime 
or  at  night,  during  the  sleeping  or  waking  condition,  and  do  not  seem 
to  result  from  any  particular  excitement  at  the  time.  If  the  patient 
is  sitting  and  talking,  or  is  engaged  in  work,  she  suddenly  ceases  and 
slowly  sinks  down  to  the  floor;  she  turns  her  head  to  one  side,  almost 
ceases  to  breathe,  becomes  pale  and  trembles,  sometimes  very  gently, 
sometimes  violently.  This  state  lasts  only  for  a  few  seconds ;  she 
arouses,  looks  about  confusedly,  and,  although  she  knows  she  has  had 
a  fit,  as  her  friends  call  it,  she  does  not  remember  distinctly  anything 
which  passed  during  the  time.  As  these  attacks  become  chronic,  they 
may  be  attended  with  very  slight  convulsive  movements,  frothing  at 
the  mouth,  and  sequential  somnolence ;  but,  ordinarily,  this  is  not  the 
case.  If  the  patient  is  attacked  in  the  night  while  asleep,  unless  some 
person  observes  the  attack,  it  will  not  be  known  to  have  occurred,  the 
patient  being  unconscious  of  it.  There  is  generally,  however,  move- 
ment enough  to  awaken  anybody  who  may  be  in  the  same  bed  with 
the  patient.  In  all  cases  of  this  kind  I  have  noticed  great  impair- 
ment of  memory,  particularly  of  recent  occurrences.  There  is  not 
usually  any  severe  pain  in  the  head  or  spinal  centres ;  there  is,  in  fact, 
no  prominent  painful  circumstance  apparently  connected  with  the 
case.  Patients  having  such  paroxysms  are  generally  worse  at  or  near 
the  time  of  menstruating ;  but  sometimes  they  are  quite  exempt  from 
them  at  this  time,  but  have  them  not  long  after  the  menstrual  conges- 
tion is  over. 

Moral  and  Mental  Derangement. 

No  more  constant  derangements,  perhaps,  occur  than  are  observed 
in  the  mental  and  moral  qualities  of  the  patient.  The  patient  loses 
the  complete  control  which  she  has  been  in  the  habit  of  exercising 
over  her  emotions,  and  finds  herself  becoming  despondent,  fretful, 
suspicious,  and  unsteady  in  her  purpose  :  whimsical,  having  desires 
not  before  experienced,  indulging  in  thought  and  feelings  toward  her 
friends  which  in  her  former  da3^s  she  did  not  entertain.  She  will  often 
call  herself  a  changed  woman.  If  the  source  of  irritation  is  not  dis- 
covered and  removed,  she  loses  her  strength  of  will  entirely ;  and, 
instead  of  her  moral  feelings  being  guided  by  her  will  under  the  in- 
fluence of  a  sound  judgment,  she  exhibits  indecision,  and  wavers  in 
matters  about  which  she  heretofore  had  no  difficulty  in  making  decision. 
She  finds  herself  giving  way  to  peevishness  to  a  frightful  degree ;  no- 
body can  please  her.  In  place  of  her  usual  satisfaction  in  the  atten- 
tion of  her  friends,  she  finds  fault  with  their  efforts  to  make  her  com- 
fortable. Sourness,  moroseness,  jealousy,  carelessness,  timidity,  and 
peculiar  perverseness  change  her  nature  entirely.  Sometimes  one  class 
of  ideas  will  seize  her  whole  faculties,  and  she  will  scarcely  think  or 
talk  of  anything  else.     She  has  no  patience  with  anybody  who  will 


358      SYMPATHETIC   OR    REFLEX   SYMPTOilS   OF    UTERINE    DISEASE. 

not  listen  to  her,  and  believes  everybody  to  be  her  enemy  vrho  cannot 
sympathize  with  her  in  her  imaginary  troubles.  The  different  phases 
of  mental  and  moral  troubles  under  which  the  patient  labors  are  al- 
most innumerable.  As  will  be  seen,  this  state  of  things  closely  borders 
on  insanity,  and  there  is  no  doubt  that  insanity  is  often  the  result  of 
uterine  irritation  in  patients  who  are  hereditarily  predisposed  to  it. 
I  think  I  have  seen  cases  of  insanity  that  were  excited  into  activity 
by  the  great  nervous  irritation  connected  with  uterine  disease.  But 
in  place  of  this  steady  deviation  from  her  natural  mental  condition, 
the  j^atient  may  generally  be  sane,  and  show  an  abnormal  state  of 
mind  only  when  circumstances  occur  which  are  likely  to  excite  her, 
when  she  loses  all  control  and  indulges  in  excessive  anger.  Some- 
times, in  a  fit  of  despondency  or  melancholy,  she  contemplates  or  even 
attempts  suicide.  Or,  if  her  sense  of  wrongs  weighs  heavily  upon 
her,  and  no  means  of  redress  shows  itself,  she  thinks  seriously  of 
fleeing  from  what  she  fancies  is  the  cause  of  them.  Still  another  sort  of 
paroxysm  exhibits  acts  of  a  depraved  and  indecent  nature,  so  disgust- 
ing as  to  shock  the  witnesses  of  them,  and  in  her  recollection  of  them 
to  mortify  her  exceedingly.  The  common  hysterical  paroxysm  of 
crying  without  a  sufiicient  cause,  the  indulgence  in  unbecoming  and 
unseemly  levity,  rapid  alternations  of  despondency  and  hope,  need 
hardly  be  mentioned,  from  their  familiarity  to  every  observer.  When, 
in  reference  to  such  unbecoming  exhibitions,  patients  are  kindly  re- 
monstrated with,  they  will,  in  general,  acknowledge  the  impropriety 
of  them,  but  will  end  with  saj'ing,  "  I  cannot  help  it,"  which  is  the 
unanswerable  and,  doubtless,  truthful  exposition  of  their  mental  con- 
dition. Neglect  of  duty  in  all  the  relations  of  life  is  one  of  the  phases 
of  their  mental  state.  Sometimes  a  wilful  selfishness,  caring  for  noth- 
ing but  what  they  fancy  will  make  them  happy  or  conduce  in  some 
way  to  their  interests,  absorbs  their  whole  mind  and  governs  all  their 
actions.  At  times  there  is  an  intelligent  appreciation  of  the  impro- 
priety of  their  actions. 

Cephalalgia. 

Cephalalgia,  in  some  form,  either  partial  or  general,  is  a  very  com- 
mon attendant  upon  the  nervous  susceptibility  of  uterine  patients. 
It  is  often  general ;  the  whole  head  seems  to  pulsate  and  thrill  with 
terrible  pain,  rendering  the  patient  almost  frantic  with  the  intolerable 
aching.  In  a  few  hours  it  subsides,  leaving  the  nervous  energies  pros- 
trate for  a  short  time,  but  otherwise  the  patient  is  free  from  all  pain. 
This  subsidence  would  not  be  complete  if  the  cephalalgia  were  any- 
thing but  nervous  pain  in  the  head.  The  general  cephalalgia  is  often, 
but  not  necessaril}^,  attended  by  nausea  and  vomiting,  or  other  sto- 
machic, hepatic,  or  intestinal  disorders,  and  may  be  relieved,  when 
that  is  the  case,  by  emesis  or  an  alterative  cathartic.     This  is  what  is 


CEPHALALGIA.  359 

commonly  called  sick  headache.  The  most  frequent  forms  of  pain  in 
the  head,  however,  are  partial,  and  confined  to  some  particular  part ; 
as  hemicrania,  confined  to  the  whole  of  one  side,  or  a  lancinating  pain 
in  the  temple,  brow,  or  eye.  All  these  are  very  common  pains  in 
uterine  disease ;  but  persistent  or  frequently  recurring  pain  in  the 
occipital  region,  or  on  the  summit  of  the  head,  is  nearly  pathogno- 
monic of  uterine  disease.  It  is  almost  invariably  the  case  that  a 
woman  has  chronic  uterine  disease  if  she  complain  of  ]3ersistent  pain 
in  either  of  these  regions.  The  occipital  pain  I  have  observed  in  this 
connection  much  oftener  than  the  pain  on  the  top  of  the  head.  It  is, 
ordinarily,  a  dull  aching,  that  completely  unnerves  the  patient  and 
renders  her  unfit  for  her  duties  for  days  together ;  it  is  usually  very 
persistent,  in  some  patients  being  almost  constantly  present,  but  in 
other  cases  only  occurring  once  a  month,  ordinarily  at  the  menstrual 
period.  The  pain  on  the  top  of  the  head  is  described  generally  as  a 
burning  pain;  patients  complain  that  they  have  all  the  time  a  hot 
place  on  the  top  of  their  heads.  This  pain  is  probably  more  constant 
in  patients  that,  have  it  than  any  other  about  the  head.  I  have  ob- 
served that  when  patients  suffer  greatly  from  pain  in  the  head,  they 
comjilain  less  of  suffering  which  is  more  directly  referable  to  the 
uterus  than  when  any  other  symptom  seems  to  predominate.  Indeed, 
I  have  met  with  patients  who  were  martyrs  to  these  excruciating  head- 
aches who  did  not  complain  of  anything  which  pointed  directly  to 
the  uterus  as  the  origin  of  their  sufferings,  and  yet  upon  examination 
that  organ  was  found  ulcerated  and  inflamed ;  and  when  these  con- 
ditions were  cured  by  appropriate  treatment,  the  headache  ceased  to 
annoy  them.  A  remarkable  instance  of  this  kind  occurred  to  me 
several  years  ago.  The  patient  came  to  town  to  consult  me  about 
what  she  called  neuralgia.  The  pain  was  located  in  the  occiput ;  it 
lasted  one  week  in  every  four  (her  menstrual  week),  and  when  very 
severe  she  had  hysterical  convulsions.  This  took  place  at  almost 
every  recurrence  of  the  headache.  She  had  no  backache  at  any  time  ; 
her  menses  were  natural  in  every  respect,  as  far  as  I  could  gather 
from  her  history,  on  which  I  placed  the  more  reliance  from  the  gen- 
eral intelligence  of  the  patient.  She  could  walk  long  distances  with- 
out inconvenience,  had  no  pains  in  the  hips,  groins,  or  legs ;  in  short, 
she  made  no  complaint  from  which  I  could  infer  the  origin  of  the 
nervous  suffering  to  be  in  the  uterus,  except  that  the  headache  was 
sure  to  come  on  at  the  time  of  menstruation.  Her  uterus  was  ulcer- 
ated and  hiflamed,  and  after  appropriate  treatment  was  cured,  when 
the  sufferings  vanished,  and  she  has  since  enjoyed  complete  immunity 
from  them.  This  woman  was  about  thirty  years  old  and  in  the  midst 
of  her  childbearing  period,  and  it  might  hence  be  supposed  that  the 
uterus  would  exercise  more  sj^mpathy  than  at  any  other  time  of  life ; 
but,  as  the  following  case  will  show,  this  is  not  the  fact:  Mrs. , 


360      SYMPATHETIC   OE   KEFLEX   SYMPTOMS    OF    UTEETNE    DISEASE. 

forty-nine  years  of  age,  had  ceased  to  menstruate  three  years  before  I 
saw  her,  but  was  subject  to  the  most  excruciating  headache  every  six 
or  seven  days,  each  attack  so  prostrating  her  that  she  would  scarcely 
recover  from  one  before  the  next  would  appear.  She  had  some  back- 
ache and  inconvenience  in  walking,  but  these  symptoms  scarcely 
attracted  her  attention  amid  the  terrible  sufferings  caused  by  her  head- 
aches. Six  months'  treatment  addressed  to  the  uterus  alone  sufficed 
to  remove  all  this  great  trouble  and  render  the  woman  comfortable 
and  capable  of  her  duties  in  life.  The  overwhelming  influence  of 
this  terrible  cephalalgia  on  the  nervous  system  seems  to  occupy  so 
completely  the  capacities  of  it  that  minor  pain  is  unheeded,  and  no 
cognizance  is  taken  of  the  sufferings  of  the  less  sensitive  but  inflamed 
and  mischief-making  uterus. 

Affections  of  the  Spinal  Cord. 

The  spinal  cord  seems  to  partake  very  much  of  the  sensitiveness 
of  the  nervous  system,  probably  more  so  than  the  brain.  Pain  in 
some  portion  of  the  spine  is  almost  universally  present  in  uterine 
disease,  but  is  most  common  in  the  sacral  and  lumbar  regions.  Pain 
is  so  general  in  those  regions  that  it  has  come  to  be  regarded  as  neces- 
sary, in  the  estimation  of  very  many  persons,  to  establish  the  probable 
existence  of  this  affection.  The  pain  is  fixed  and  almost  constant, 
but  aggravated  by  anything  that  excites  the  uterine  vascular  system, 
as  standing  or  walking  for  a  long  time,  lifting  or  jumping,  or  sudden 
emotions.  Fright,  anxiety,  or  anger,  as  the  patient  says,  "  flies  to 
the  back  "  and  aggravates  the  pain.  It  is  especially  apt  to  be  worse 
during  the  menstrual  congestion.  Sometimes  walking  so  much  in- 
creases it  as  to  incapacitate  the  subject  for  that  kind  of  exercise.  An 
expression  often  made  use  of  to  signify  sensitiveness  of  the  back,  is 
"  weak  back."  Women  will  say,  "  I  have  not  exactly  pain  in  my 
back,  but  it  is  so  weak  that  I  cannot  move  on  account  of  it,  or  can 
hardly  stand,  or  cannot  arise  from  a  stooping  posture."  The  pain 
may  be  fixed  in  any  part  of  the  spine.  I  have  a  patient  whose  back- 
ache is  at  the  junction  of  the  dorsal  and  lumbar  regions.  In  connec- 
tion with  these  pains  there  is  often  tenderness  in  the  same  region,  so 
that  pressure  causes  great  complaint.  The  pain  is  not  only  increased 
in  the  part  pressed  upon,  but  it  sometimes  darts  along  the  nerves 
around  the  body. 

Hypersesthesia. 

Akin  to  pains  in  various  parts  is  hypertesthesia  without  inflamma- 
tion ;  great  sensitiveness  of  particular  parts.  Tenderness  of  the  scalp 
is  often  complained  of  The  whole  surface  of  the  head  is  so  tender 
as  to  require  great  care  in  dressing  it,  and  no  pressure  can  be  toler- 
ated without  an  effort.     Of  a  similar  nature  is  tenderness  along  the 


EXTENSION  OF  INFLAMMATION  TO  THE  BLADDER  AND  EECTUM.     361 

spine.  The  different  spinous  processes  in  some  sections  of  the  column 
cannot  be  touched  without  giving  the  patient  great  suffering.  Pres- 
sure upon  these  tender  vertebrje  sometimes  causes  pain  to  shoot  along 
the  spinal  nerves,  passing  out  of  the  intervertebral  foramina  in  the 
neighborhood.  There  is  occasionally,  also,  general  tenderness  of  the 
abdomen. 

Ansesthesia. 

Much  less  frequently  there  is  ansesthesia  of  some  particular  parts. 
The  patient  complains  of  a  want  of  the  ordinary  sensitiveness  in 
them,  or  there  is  a  feeling  of  numbness,  which  lasts  for  some  days, 
and  which  recurs  so  often  as  to  obtain  the  distinction  of  a  symptom 
of  the  case. 

The  muscular  through  the  nervous  system  is,  in  many  cases,  very 
seriously  affected.  Cramps  and  spasmodic  action  are  very  frequent 
in  particular  cases,  and  they  are  confined  almost  constantly  to  certain 
limbs.  They  occur  more  frequently  in  the  lower  than  in  the  upper 
extremities. 

Spasms. 

A  worse  state  of  things,  however,  exists  when  there  are  general 
spasms  of  the  limbs  and  abdominal  walls  and  hysterical  convulsions. 
They  are  apparently  induced  by  fatigue,  or  occur  at  the  time  of  men- 
struation. The  patient,  after  complaining  of  severe  pain  in  the  stom- 
ach, falls  into  a  state  of  general  convulsions,  which  lasts  from  thirty 
seconds  to  some  hours,  and  subsequently  sinks  into  a  state  of  quietude, 
but  not  of  insensibility.  These  attacks  are  usually  repeated  several 
times  and  then  subside,  leaving  the  patient  in  the  possession  of  her 
usual  physical  condition,  which  is  one  of  nervous  misery. 

Sympathetic  Pains  in  the  Pelvic  Region. 

Painful  localities  are  generally  found  about  the  pelvis ;  in  the  in- 
guinal or  internal  iliac  region  they  are  exceedingly  common.  Imme- 
diately above  one  of  the  groins  a  constant  and  fixed  aching  may  be 
found,  which  is  aggravated  by  all  the  circumstances  that  increase  the 
pain  in  the  back.  Most  generally  there  is  some  tenderness  or  soreness 
in  the  part,  which  is  increased  by  pressure.  The  pain  sometimes  ex- 
tends to  the  hip  and  side  of  the  pelvis.  It  is  much  more  frequent  in 
the  left  side,  but  is  often  confined  exclusively  to  the  right,  and  less 
frequently  it  is  in  both  sides  alike.  In  more  rare  instances  the  pain 
is  centrally  situated  behind  the  symphysis  pubis. 

Extension  of  Inflammation  to  the  Bladder  and  Rectum. 

The  patient  will  often  say  she  has  pain  in  the  bladder,  or  pain 
in  the  rectum,  and  believes  that  these  regions   are  affected.    These 


362      SYMPATHETIC    OR    REFLEX    SYMPTOMS    OP   UTERINE   DISEASE. 

pains,  when  complained  of,  are  generally  very  ajapropriately  stated 
to  be  in  the  bladder  and  rectum,  and  are  indicative,  for  the  most 
part,  of  an  extension  of  inflammation  to  these  two  organs.  When 
this  is  the  case,  pain  accompanies  or  rather  is  increased  by  mic- 
turition, or  may  occur  immediately  after  it.  The  same  remarks  are 
applicable  to  the  alvine  discharge ;  during  defecation  the  pain  is 
increased,  or  then  only  occurs.  These  pains  are  not,  strictly  speak- 
ing, sympathetic,  but  occur  as  consequences  of  the  extension  of  in- 
flammation, and  indicate  correctly  its  locality.  In  the  iliac  region 
it  sometimes  extends  up  the  side  as  far  as  the  mammary  region,  or 
there  may  be  pain  in  this  latter  place  not  connected  with  the  former. 
The  pain  may  likewise  be  situated  between  these  localities  and  be 
independent  of  any  pain  in  them. 

Affections  of  the  Sciatic  and  Anterior  Crural  Nerves. 

Pain  in  the  course  of  the  sciatic,  obturator  or  anterior  crural  nerves 
is  very  common  in  uterine  affections  of  an  inflammatory  nature.  It 
is  often  so  severe  and  aggravated  by  exertion  as  to  incapacitate  the 
patient  for  walking.  Particular  motions  cause  pain  according  to  the 
nerve  affected.  When  the  sciatic  is  the  S'^at  of  pain,  sitting  down, 
especially  on  a  hard  chair,  increases  it,  so  that  the  patient  resorts  to 
cushions  for  defence  against  pressure.  Pain  in  the  course  of  one  or 
more  of  these  nerves  is  often  the  most  distressing  circumstance  con- 
nected with  the  case,  and  it  is  often  treated  as  neuralgia  seated  in  the 
nerves,  while  the  cause  is  not  even  suspected.  The  pain  may  occupy 
the  whole  length  of  the  nerve,  or  it  may  be  confined  to  its  upper  or 
lower  parts,  or  to  an  intermediate  portion  of  variable  length.  The 
part  of  the  limb  traversed  by  the  nerve  may  be  tender  or  not ;  most 
frequently  there  is  no  tenderness.  The  pain  may  be  fixed,  or  darting 
and  transitory.  It  may  be  constant  or  paroxysmal ;  the  patient  may 
enjoy  immunity  for  hours  and  days,  or  even  weeks,  or  she  may  be  a 
constant  sufferer  from  them.  They  are  apt,  as  other  pains  are,  to  be 
greater  during  menstrual  congestion  than  at  any  other  time.  The 
pains  emanating  from  the  pelvis  are  not  sympathetic,  nor  are  they 
probably  reflex ;  but  they  are  caused  very  likely  by  pressure  of  the 
uterus,  or  they  may  be  produced  by  an  extension  of  the  inflamma- 
tion to  the  nerve-sheaths. 

Muscular  Weakness. 

Extreme  muscular  weakness — I  do  not  mean  that  which  results 
from  general  debility,  but  of  some  particular  set  of  muscles — is  often 
present  as  an  accompaniment  of  uterine  disease.  This  is  most  frequent 
in  the  back  and  lower  extremities,  not  often  in  the  upper  extremities. 
It  is  probably  imperfect  innervation  of  the  part,  or  it  may  be  some 


CIRCULATORY   SYSTEM.  363 

affection  of  the  muscles  themselves.  I  have  been  inclined  to  look  upon 
it  as  partial  paralysis,  resulting  from  reflex  irritation.  More  or  less 
numbness  of  the  parts  exists  in  connection  with  the  weakness  of  the 
muscles. 

Circulatory  System. 

The  circulation  and  its  organs  are  very  often  deranged  to  a  distress- 
ing degree.  Palpitation  of  the  heart  is  often  troublesome,  and  patients 
are  apt  to  think  themselves  the  subjects  of  disease  of  the  heart.  We 
are  often  consulted  solely  with  reference  to  this  symptom,  it  having 
absorbed  the  attention  and  awakened  the  apprehension  of  the  sufferer 
to  such  a  degree  that  her  other  inconveniences  were  forgotten  or  over- 
looked. These  palpitations  are  sometimes  attended  with  pain  in  the 
region  of  the  heart,  which  occasionally  shoots  up  to  the  left  shoulder 
and  down  the  left  arm  to  a  greater  or  less  distance,  the  distress  being 
so  great  as  to  amount  almost  to  angina.  The  palpitation  is  worse 
during  nervous  excitement.  It  occurs  generally  in  paroxysms.  We 
meet  with  instances  in  which  it  oftener  occurs  after  lying  down  at 
night  than  at  any  other  time.  Sometimes  it  seems  to  be  increased 
during  digestion.  The  sensation  of  palpitation  does  not  seem  to  be  at 
all  commensurate  with  the  increased  excitement  of  that  organ,  and 
vice  versa.  I  have  observed  instances  in  which  the  patient  complained 
of  violent  jDalpitation,  while  the  pulse  and  heart,  as  far  as  I  could 
judge,  were  not  at  all  disturbed.  In  such  cases  we  might  say  that  the 
sensitiveness  of  the  heart  was  increased  until  its  ordinary  motions 
were  perceived  by  the  patient.  Indeed,  the  pains  and  increased  irri- 
tability of  the  organs  supplied  with  the  great  sympathetic  nerve  seem 
to  result  from  increased  susceptibility  or  sensitiveness  instead  of 
organic  changes.  There  is  also  sometimes  a  sensation  of  throbbing, 
as  though  the  blood  was  passing  through  the  arteries  in  increased 
quantities,  and  with  increased  force  in  some  j^arts  of  the  system ;  this 
occurs  mostly  about  the  head,  sometimes  in  the  hands  and  feet,  and 
occasionally  inside  the  head,  apparently  in  the  brain ;  also  about  the 
genital  organs.  Great  irregularity  of  distribution  of  the  blood  is  often 
observable,  the  hands  and  feet  being  uncomfortably  cold,  and  continu- 
ing in  that  state  for  twenty-four  hours  at  a  time.  In  connection  with 
cold  extremities,  the  head  is  apt  to  be  hot,  or  warmer  than  natural; 
this  heat  of  the  head  may  also  be  present  when  the  feet  and  hands  are 
of  the  common  temperature.  The  heat  about  the  head  and  face  is 
sometimes  almost  constantly  present  in  certain  patients,  and  is  the 
source  of  great  annoyance  to  them.  It  is  apt  to  be  caused  by  anything 
that  excites  the  person.  The  heat  is  greatest  and  frequently  exclusively 
located  on  the  top  of  the  head.  I  do  not  think  that  this  sensation  of 
heat  arises  from  any  other  cause  as  frequently  as  from  uterine  disease, 
and  I  am  sui'e  it  is  one  of  the  most  common  symptoms  in  such  dis- 


364      SYMPATHETIC   OR  EEFLEX   SYMPTOMS   OF   UTERINE   DISEASE. 

ease.  There  is  great  heat  complained  of  in  the  back  of  the  head  also, 
in  many  instances,  and  sometimes  it  extends  along  the  spine,  atfecting 
the  whole  or  only  sections  of  it.  Burning  in  the  sacrum  and  loins  is 
very  common.  Flashes  of  heat  and  flushes  of  color  in  the  face  and 
head,  and  even  in  other  parts  of  the  body,  are  very  common  and 
annoying  occurrences.  The  power  of  nervous  energy  of  the  heart  may 
be  impaired  to  such  an  extent  as  to  render  the  patient  liable  to  faint- 
ness  from  very  slight  causes — anger,  fear,  surprise,  or  even  the  more 
tender  emotions,  overcoming  the  patient  very  readily. 

Re^iration. 

The  respiratory  apparatus  is  not  so  frequently  or  so  severely  affected 
as  some  of  the  rest  of  the  organization,  and  yet  we  often  meet  with 
some  very  curious  and  considerable  deviations  from  the  natural  con- 
dition of  its  functions.  The  constriction  about  the  throat,  or  the 
feeling  as  if  a  ball  rose  to  the  throat  and  obstructed  respiration,  and 
the  feeling  as  if  smoke  or  dust  were  in  the  air  which  the  patients 
breathe,  are  complaints  we  hear  almost  every  day.  All  the  sensa- 
tions, or  any  one  of  them,  may  be  aggravated  to  an  agonizing  degree, 
inducing  the  fear  that  the  paroxysm  may  be  fatal,  and  causing  the 
patient  to  suffer  for  some  moments,  and  sometimes  for  hours,  the 
horrible  sensations  of  impending  suffocation.  The  breathing  may  be 
spasmodic  from  painful  and  unnatural  contractions  of  the  respiratory 
muscles.  There  may  also  be  pleurodynic  pains  during  each  ordinary 
effort  of  respiration.  Imperfect  respiration,  or  partial  inflation  of 
one  lung,  or  of  parts  of  the  lungs,  occasionallj^  occurs.  The  modifi- 
cation of  the  respiratory  murmur  arising  from  this  imperfect  inflation 
of  one  of  the  lungs  I  have  observed  on  several  occasions,  and  not 
without  serious  apprehension  of  the  result;  but  in  all  cases  where  this 
was  the  only  modification  of  physical  sounds,  the  patients  have  done 
well,  and  the  inflation  improved  as  the  returning  nervous  energy  of 
the  rest  of  the  system  was  established.  The  respiration  is  not  often 
hurried  as  a  constant  circumstance,  but  occurs  temporarily  as  the 
effect  of  excitement  from  mental  or  moral  emotions.  In  some  cases, 
amid  the  tumult  of  nervous  excitement  during  a  paroxysm,  I  have 
seen  the  respiratory  efforts  increased  to  sixty  in  a  minute ;  and,  occa- 
sionally, these  nervous  patients  constantly  have  increased  frequency 
of  respiration.  There  are  cases  in  which  cough  is  a  very  constant 
symptom ;  it  is  a  peculiar,  nervous  cough,  as  a  general  thing,  and  is 
excited  or  made  worse  by  anything  that  renders  the  patient  more 
nervous.  Sometimes  it  is  difficult  to  distinguish  it  from  the  coughs 
which  arise  from  insidious  affections  of  the  lungs.  It  is  possible  that 
the  cough  arising  from  slight  lung  difficulties  may  be  aggravated 
by  the  nervousness  consequent  upon  uterine  disease.     I  once  saw  a 


SYMPATHY   OF   THE   EXCRETOEY   ORGANS.  365 

patient  affected  with  a  peculiar  nervous  cough,  as  the  effect  of  uterine 
disease,  which  sounded  like  the  barking  of  a  small  dog,  and  the  sound 
was  made  at  every  expiration  during  the  waking  condition  of  the 
patient,  except  when  the  mind  was  intensely  occupied.  She  was  an 
intelligent  young  married  woman,  about  twenty  years  of  age.  While 
her  whole  attention  was  absorbed,  she  forgot  to  cough,  but  as  soon  as 
her  attention  was  relaxed,  she  habitually  produced  the  same  sound. 
This  had  lasted  when  I  saw  her  six  months  or  more.  When  she  was 
embarrassed  by  a  conversation  which  related  to  her  case,  the  sounds 
became  much  louder  and  persistent,  appearing  in  perfect  synchronism 
with  every  respiratory  effort.  I  must  further  add  that  I  did  not  have 
an  opportunity  to  treat  this  patient,  nor  have  I  heard  from  her,  so 
that  I  cannot  give  her  subsequent  history ;  but  the  rest  of  the  symp- 
toms plainly  indicated  uterine  suffering,  and  an  examination  estab- 
lished the  fact  that  she  had  ulceration  and  inflammation  of  the  neck 
of  the  uterus.     She  had  never  borne  children  or  miscarried. 

Sympathy  of  the  Excretory  Organs. 

The  excretory  organs  also  sympathize  with  the  uterus,  particularly 
the  kidneys.  It  has  been  for  a  long  time  observed  that  female  pa- 
tients, in  a  state  of  nervous  excitement,  secrete  a  large  quantity  of 
urine,  which  is  usually  limpid,  almost  odorless  and  insipid.  These 
qualities  are  most  likely  dependent  upon  the  amount  of  water  being 
so  much  greater  proportionately  than  the  salts ;  these  last  scarcely 
seem  to  be  present  at  all.  It  is  extremely  dilute  urine.  Uterine 
patients  are  very  prone  to  large  discharge  of  limpid  urine.  This  kind 
of  alteration  in  the  functions  of  the  kidneys  is,  doubtless,  indirect, 
and  does  not  occur  except  in  connection  with  a  greatly  excited  condi- 
tion of  the  nervous  system  as  the  medium  between  the  kidneys  and 
the  uterus.  More  considerable  deviations,  however,  are  apt  to  take 
place;  the  salts  are  likely  to  be  increased  in  quantity  compared  to  the 
amount  of  water ;  or  one  sort  of  the  salts  may  be  greatly  over  or  under 
the  proper  proportions  in  relation  to  the  others.  The  urine  may  be 
decidedly  morbid  in  its  composition.  It  is  probable,  too,  that  the 
deviation  is  secondary  to  derangements  of  the  stomach  and  liver,  but, 
nevertheless,  it  is  often  present.  The  urine  may  be  highly  alkaline, 
or  highly  acid  in  reaction,  showing  the  production  to  an  unusual 
degree,  of  salts  having  such  chemical  qualities.  The  presence  of  the 
salts  in  excess,  whether  of  the  one  kind  or  the  other,  is  pretty  sure  to 
produce  painful  micturition  and  other  disagreeable  sensations,  as 
burning  and  smarting  in  the  urethra  and  bladder.  There  is  no  doubt, 
however,  that  the  painful  and  disagreeable  symptoms  may  arise  as 
the  more  direct  effect  of  inflammation  of  the  uterus  when  the  urine  is 
correct  in  composition ;  hence  the  examination  of  the  urine  will  be 


366      SYMPATHETIC   OR    REFLEX    SYMPTOMS    OP    UTERINE    DISEASE. 

necessary  to  determine  the  cause  of  the  symptoms.  But  the  urine 
is  often  secreted  in  very  diminished  quantities  in  cases  of  uterine 
disease,  and  that,  too,  without  apparent  general  febrile  excitement. 
Patients  frequently  complain  of  this  symptom.  Whether  there  is  an 
increase  in  the  excretory  functions  of  the  skin  at  such  time  I  am 
unable  to  say.  The  skin  is  probably  not  very  much  affected  in  its 
excretory  capacity  as  a  general  thing,  but  some  very  curious  devia- 
tions have  been  observed. 

Mammary  Bodies. 

More  direct  are  the  effects  upon  the  mammary  bodies.  They  are 
often  highly  excited  by  uterine  disease ;  this  is  no  more  than  would 
have  been  expected  from  the  close  sympathetic  relations  between  these 
organs.  Congestion  is  the  most  common  sympathetic  condition.  The 
mammge  increase  in  size,  become  hot  and  painful  as  a  general  thing, 
but  sometimes  there  is  no  change  in  their  sensible  or  sensitive  con- 
ditions. The  appearances  are  natural,  but  the  patient  complains  of  a 
peculiar  and  painful  condition,  not  unlike  the  sensations  perceived 
during  the  suppurative  stage  of  inflammation:  but  there  is  neither 
tenderness,  nor  swelling,- nor  heat,  nor  other  deviation  than  the  un- 
natural sensation.  Sometimes  the  breasts  are  really  inflamed.  The 
lymphatic  glands  in  the  axilla,  and  from  the  axilla  to  the  border  of 
the  mammse,  in  some  cases,  become  affected  at  the  same  time;  in 
other  instances,  however,  they  do  not  partake  in  the  sympathies  of 
the  mammse.  They  also  become  tender  in  some  cases  when  the 
mammse  do  not  seem  to  be  excited. 

I  have  dwelt  so  long  on  these  general  symptoms,  and  have  made 
so  much  of  uterine  sympathies,  that  I  am  forced  to  recall  an  expres- 
sion made  use  of  in  a  notice  of  Professor  Hodge's  work  on  Diseases  of 
Women,  that  "  if  all  this  is  true,  it  is  almost  a  pity  that  a  woman  has 
a  womb  ;"  but  I  have  fallen  very  far  short  of  mentioning  all  the  sym- 
pathetic evils  resulting  from  chronic  diseases  of  the  uterus,  and  I 
only  design  this  as  an  outline  view  of  a  subject  that  will  fill  itself  up 
in  painfully  warm  colors  in  the  observation  of  those  who  devote  them- 
selves to  a  close  study  of  the  diseases  of  women.  While  this  is  my 
conviction,  I  do  not  wish  to  be  understood  as  saying  that  nearly  all 
of  the  above  symptoms  will  show  themselves  even  in  a  majority  of 
cases ;  some  of  them  will  be  prominent  in  some  cases,  others  in  other 
cases ;  and  in  rare  instances  we  meet  with  nearly  all  of  them  in  some 
sufferer,  and  in  nearly  all  chronic  cases  we  shall  find  enough  to  move 
us  to  commiseration  for  the  ruined  health  of  women  thus  affected. 
I  know  there  are  thousands  of  my  peers  in  the  profession  who  do  not 
see  in  the  foregoing  array  of  symptoms  any  indication  of  disease  of 
the  uterus,  and  when  uterine  diseases  are  obviously  coexistent,  they 
are  not  arranged  in  the  order  of  sequency.     This  does  not  shake  my 


MAMMARY   BODIES.  367 

faith  in  the  facts  I  have  observed  for  myself,  nor  disturb  my  judg- 
ment, formed  from  an  observation  of  a  very  large  number  of  cases 
carefully  watched  through  all  stages  of  progress  to  their  termination. 
That  all  the  above  symptoms  may  occasionally  be  present  in  cases  in 
which  the  uterus  is  healthy,  I  have  often  observed ;  but  that  they  are 
also  j)resent  as  the  proximate  and  remote  effects  of  uterine  disease,  I 
am  well  satisfied.  Another  well-established  fact,  according  to  my 
judgment,  is,  that  the  direct  symptoms  referable  to  the  uterus  may  be 
feebly  pronounced,  while  some,  or  even  a  large  number,  of  the  sym- 
pathetic disturbances  are  very  prominent ;  and,  judging  by  the  free- 
dom from  pain  and  other  inconveniences  in  the  uterine  region,  there 
are  even  cases  in  which  the  uterus  does  not  seem  to  suffer  at  all. 
These  cases  are  well  calculated  to  mislead  us,  and  to  induce  the 
opinion  that  the  womb  difficulty  is  of  minor  importance,  and  need 
not  be  the  object  of  solicitude  until  we  get  rid  of  the  more  troublesome 
and  prominent  symptoms.  We  cannot  be  too  careful  in  our  consid- 
eration and  management  of  this  class  of  cases,  and  while  we  adopt 
judicious  remedial  means  for  the  removal  of  the  more  afflictino- 
symptoms,  we  must  address  ourselves  to  the  disease  of  the  uterus 
however  slight  it  may  appear  to  be.  I  have  seen  too  much  good 
result  from  the  observance  of  this  direction  not  to  dwell  with  emphasis 
upon  its  importance.  The  cure  of  the  uterine  disease  will  be  a  valu- 
able diagnostic  measure  in  such  cases.  Not  only  may  there  be  a 
,  great  difference,  or  want  of  correspondence,  in  the  severity  of  the 
local  and  general  symptoms,  but  in  many  cases  m  which  the  general 
symptoms  have  almost  made  a  wreck  of  the  health  and  happiness  of 
the  patient,  the  local  inflammation  and  ulceration  will  be  found  upon 
examination  to  be  trifling  in  amount  and  degree.  The  inflammation 
may  be  very  slight  and  the  patient  suffer  very  greatly  from  it,  either 
generally,  or  locally,  or  both ;  or  the  ulceration  may  be  extensive  and 
the  inflammation  very  considerable,  and  yet  the  patient  hardly  be 
sensible  of  any  inconvenience  whatever  from  its  presence.  This  state- 
ment will  be  confirmed  by  careful  observers  in  this  field  of  research. 
This,  however,  will  prove  a  stumbling-block  to  those  who  entertain 
the  opinion  that  uterine  disease  is  of  small  importance  in  the  consid- 
eration of  woman's  ailments.  They  seem  to  think  that  there  is  of 
necessity  an  exact  and  invariable  seeming  correspondence  between  the 
magnitude  of  cause  and  effect,  and  they  point  to  these  cases  and  say, 
the  symptoms  were  present,  but  a  very  trifling,  if  any,  uterine  disease 
showed  itself  upon  examination  ;  or,  they  will  say,  there  was  great 
ulceration,  but  the  patient  did  not  suffer  from  its  presence,  at  least 
not  in  proportion  to  the  amount  of  local  disease.  I  need  not  particu- 
larize instances  in  which  other  diseases  are  comparatively  latent,  or 
cases  in  which   the  symptoms   are   unduly  severe  compared  to  the 


368      SYilPATHETIC   OE   REFLEX   SYMPTOilS   OF   UTEEINE   DISEASE. 

amount  of  actual  disease,  as  they  will  suggest  themselves  to  every 
intelligent  practitioner. 

But,  recurring  to  the  sympathies  of  the  uterus,  we  find  that  while 
some  patients  are  not  affected  at  all  by  pregnancy,  and  others  favorably 
affected,  their  health  being  better  then  than  at  any  other  time,  that 
some  absolutely  perish  on  account  of  the  functional  derangements 
inaugurated  by  pregnancy  ;  and,  as  is  shown  on  a  former  page,  organic 
diseases  are  not  unfrequently  lighted  up.  We  shall  probably  always 
be  at  a  loss  to  understand  precisely  this  difference ;  but  there  can  be 
no  doubt  that  it  is  more  on  account  of  constitutional  differences  than 
local  ones.  The  concatenation  of  sympathetic  influences  may  be 
caused  by  the  greater  susceptibility  of  the  organs  secondarily  affected. 
In  fact,  the  only  mode  of  accounting  for  it  is  by  supposing  this  in- 
creased susceptibility.  I  am  convinced  that  this  great  but  inexplicable 
diversity  of  sympathetic  effects  is  as  likely  to  result  from  uterine 
disease  as  from  pregnancy.  We  must,  therefore,  expect  a  very  great 
range  of  difference  in  the  extent  of  sympathetic  derangement  from 
uterine  disease.  It  is  interesting  to  observe  the  rise  and  development 
of  the  sequences  to  diseases  of  the  uterus.  How  far  can  the  uterus 
produce  a  direct  effect  in  creating  this  large  amount  of  sympatlietic 
disorder?  Are  most  of  the  symptoms  produced  by  the  direct  sympa- 
thetic relation  of  the  uterus  to  other  organs,  or  does  the  diseased 
uterus  first  affect  some  other  more  influential  organ  detrimentally,  and 
then  this  last  the  organism  generally  ?  I  am  inclined  to  think,  from 
a  large  observation,  that  the  uterus  has  close  sympathy  with  only  a 
few  organs,  and  no  one  probably  is  so  powerfully  affected  by  it  as  the 
stomach.  It  is  the  first  organ  affected  in  jDregnancy,  being  brought 
into  a  morbid  condition  in  a  very  few  weeks.  The  well-known,  power- 
ful, and  almost  universal  sympathetic  influence  exerted  by  the  stomach 
upon  other  viscera  is  sufiicient,  when  it  is  diseased,  to  account  for  the 
great  variety  of  subsequent  symptoms.  The  stomach  is  the  great 
centre  from  which  radiate  abdominal,  thoracic,  cerebral,  and  spinal 
disturbances  almost  ad  infinitum;  and  there  can  be  no  reasonable 
doubt  that  it  is  an  active  agent  in.  originating  the  disturbances  of  the 
great  vital  organs.  The  subject  of  the  sympathetic  influence  of  the 
uterus  then  becomes  the  more  interesting  and  important,  from  the 
fact  that  a  very  slight  deviation  from  its  ordinary  condition  arouses 
the  most  influential  of  all  the  organs  to  a  state  of  disease,  which  de- 
presses the  functional  energies  and  increases  the  susceptibilities  of 
almost  all  the  rest  of  the  organism.  In  addition  to  the  chain  of  sym- 
pathetic susceptibilities  produced  by  this  state  of  the  stomach,  fre- 
quently the  digestive  powers  of  that  organ  are  impaired  or  perverted,  so 
as  to  supply  the  chyme  in  deficient  quantities  or  in  deteriorated 
quality,  and  in  this  way  injuriously  affect  the  composition  of  the  blood, 
inducing  anaemia  or  oligsemia.     Imperfect  nutrition  will  follow,  as  a 


PAIN   IN    THE   SACRAL   OR    LUMBAR    REGION.  369 

matter  of  course,  in  the  one  case,  and  perverted  nutrition  in  the  other, 
so  that  emaciation  or  obesity  will  be  ordinarily  present.  Another 
organ,  probably,  in  direct  sympathy  with  the  uterus  is  the  cerebellum, 
as  it  seems  to  me  to  be  as  frequently  affected  as  the  stomach.  The 
mammse  are,  of  course,  in  direct  sympathetic  relation  with  the  uterus, 
and  yet  they  are  not  uniformly  affected  in  all  cases  when  the  uterus  is 
very  seriously  diseased.  I  do  not  believe  that  we  are  able  to  say  at 
present  whether  there  are  other  organs  that  come  directly  under 
uterine  influence.  A  proof  of  the  powerful  and  very  ready  effect  upon 
other  organs,  of  irritation  of  the  uterus,  may  be  found  in  the  fact,  that 
very  often  when  the  patient  is  in  a  condition  of  comfort,  so  far  as  her 
general  suffering  is  concerned,  an  application  of  nitrate  of  silver  to  a 
morbid  os  uteri  will  give  her  excruciating  pain  in  the  head,  render  her 
exceedingly  despondent  and  irritable,  and  very  much  aggravate  the 
symptoms  with  which  she  is  affected.  This  I  have  so  often  observed 
to  be  the  case  that  I  cannot  but  regard  it  as  one  of  our  diagnostic 
means.  After. such  an  application,  the  patient  will  generally  com- 
plain of  an  aggravation  of  the  general  symptoms,  whatever  they  may 
have  been,  and  say  that  all  the  pains  are  made  worse  by  the  applica- 
tion of  the  caustic.  When  an  organ  has  been  the  subject  of  irritation 
or  functional  derangement  for  a  long  time,  in  consequence  of  sympathy 
with  the  uterus,  it  may  become  the  subject  of  organic  disease,  which 
may  continue  as  an  independent  affection  of,  perhaps,  a  dangerous 
,character ;  or,  if  organic  has  not  succeeded  to  functional  disease,  the 
power  of  habit,  which  is  so  frequently  thus  engendered,  will  perpetuate 
morbid  action  for  an  indefinite  period  after  the  cause  of  it  has  been 
removed. 

LOCAL  SYMPTOMS. 

Pain  in  the  Sacral  or  Lumbar  Region. 

Pain  in  the  sacrum  is  one  of  the  most  constant,  and  when  persist- 
ent indicates,  with  a  good  deal  of  certainty,  disease  of  some  kind  in 
the  pelvis.  The  pain  in  this  region,  caused  by  the  diseases  of  the 
uterus,  is  ordinarily  central,  being  in  the  middle  of  the  sacrum  at  its 
lower  extremity.  It  is  sometimes  at  its  upper  extremity,  or  it  extends 
the  whole  length  of  the  bone.  Not  unfrequently  a  painful  spot  may 
be  found  on  one  side,  over  the  sacro-iliac  junction.  Some  patients  de- 
scribe the  pain  as  if  a  bundle  of  nerves  were  pulled  upon  from  the 
inside  of  the  sacrum,  and  others  describe  it  as  an  aching  or  burning 
pain.  Accompanying  the  pain  in  the  sacrum  is  often  a  sense  of  sore- 
ness upon  pressure,  an  inability  to  sit  with  comfort,  on  account  of  the 
tenderness  of  the  lower  part  of  the  sacrum. 

24 


370  LOCAL  SYMPTOaMS. 


Pain  in  the  Loins. 

Pain  in  the  loins  is  probably  not  so  common  as  that  in  the  sacrum, 
but  is  quite  as  various  in  its  nature.  Very  frequently  there  is  great 
weakness  in  the  loins,  so  great  in  degree  sometimes  as  to  prevent  the 
continuance  of  the  erect  posture  for  any  length  of  time.  I  have  had 
a  number  of  patients  who  were  unable  to  stand  long  enough  to  dress 
their  hair  on  account  of  a  weak  back. 

It  is  remarkable  that  patients  often  feel  this  weak  back  more  when 
standing  than  when  walking ;  and  they  are  sometimes  able  to  walk  a 
distance  without  any  great  inconvenience,  but  as  soon  as  they  stop,  the 
weakness  is  apparent  to  a  distressing  degree. 

Inability  to  Walk. 

Ordinarily  the  weakness  disables  the  patient  for  walking.  The  pain 
in  the  back  is  almost  always  increased  by  walking  or  standing,  and 
on  this  account  the  patients  avoid  being  on  their  feet,  although  the 
back  is  strong  enough.  But  there  are  many  patients  who  have  severe 
disease  of  the  uterus,  who  do  not  experience  any  of  the  inconveniences 
in  the  sacrum  and  loins  already  described ;  but  some  of  them  are  very 
generally  present. 

Great  pain  in  the  back,  closely  resembling  that  arising  fi'om  a  dis- 
eased uterus,  is  also  caused  by  hemorrhoids,  prolapse,  or  inflamma- 
tion of  the  rectum.  The  pain  caused  by  diseases  of  the  rectum,  I 
think,  is  much  more  frequent  on  the  left  side  of  the  sacrum  and  in 
the  left  nates  or  hip  than  in  a  central  position  ;  in  fact,  I  have  come 
to  regard  pain,  confined  to  the  left  nates  and  hip,  as  indicating,  with 
considerable  probability,  rectal  disease,  and  I  always  inquire  into  the 
functions  of  that  organ  when  such  pain  is  present.  It  differs  in  po- 
sition from  the  pain  in  the  iliac  region,  so  common  as  the  result  of 
uterine  disease.  It  is  situated  near  the  sacrum,  and  more  in  the  side 
of  the  pelvis  than  the  latter. 

Pain  in  the  Iliac  Region. 

Pain  in  the  iliac  region  is  very  common.  In  frequency  it  is  next  to 
pain  in  the  back.  The  pain  is  commonly  situated  a  little  anterior  to 
the  sujDerior  spinous  process  of  the  ilium,  and  below  the  level  of  it. 
It  is  not  referred  to  the  iliac  bone,  or  fossa,  but  to  a  place  a  little  above 
the  groin.  We  often  meet  with  it  on  both  sides,  but  much  more 
frequently  on  one  only  ■;  on  the  left  side  much  oftener  than  on  the  right. 
Dr.  Dewees  considered  pain  in  the  left  groin,  or  a  little  above  it,  as 
almost  diagnostic  of  prolapse  of  the  uterus.  It  is  certainly  very  fre- 
quently indicative  of  inflammation  of  the  uterine  cervix. 


LEUCOEEHCEA.  371 

Soreness  in  the  Iliac  Region. 

This  pain  is  generally  accompanied  with  soreness  upon  pressure, 
and  sometimes  there  is  soreness  upon  pressure  when  there  is  no  con- 
stant pain.  Walking,  standing,  or  riding  generally  increases  it.  A 
severe  shock  or  strain  from  lifting  will  sometimes  cause  pain  suddenly 
to  appear  in  this  region  when  it  had  not  before  been  observed. 

Pain  in  the  Side,  above  the  Ilium. 

Instead  of  the  pain  situated  as  here  described,  there  is  often  pain 
higher  up  in  the  side,  or  in  the  iliac  fossa,  or  along  the  crest  of  the 
ilium,  and  even  midway  between  the  crest  and  ribs  of  the  side.  These 
pains  are  not  in  the  ovaria,  although  they  seem  to  point  to  the  ovaria 
more  directly  than  to  the  uterus  ;  and  are  by  some  regarded  as  a  symp- 
tom arising  from  ovarian  inflammation.  Dr.  Bennett  admits  that  it 
may  be  a  sympathetic  painful  condition  of  the  ovary.  It  is  not  ma- 
terial whether  this  is  true  or  not;  it  is  certain  that  it  is  very  frequently 
present  in  uterine  disease,  and  is  almost  invariably  cured  by  remedies 
addressed  to  the  uterus  instead  of  to  the  ovaria. 

Weight,  or  Bearing-down  Pain,  or  Uterine  Tenesmus. 

Another  indication  of  uterine  disease,  of  less  frequent  occurrence, 
is  a  sense  of  weight  in  the  loins  or  pelvis.  This  sense  of  weight  is 
experienced  in  the  loins  and  iliac  regions  more  frequently  than  else- 
where ;  but  it  is  often  felt  at  the  pelvis,  and  oftener  in  the  perineal 
and  anal  regions.  Patients  express  themselves  as  feeling  a  heavy 
weight  dragging  upon  the  back  and  hips,  and  others  feel  as  though 
the  insides  were  dropping  through  the  vagina.  Occasionally  we  meet 
with  such  urgent  uterine  tenesmus  that  the  patient  is  obliged  to  keep 
the  recumbent  posture  in  order  to  enjoy  any  comfort.  In  such  cases 
the  patient  in  the  erect  position  cannot  resist  a  constant  desire  to 
"  bear  down,"  resembling  the  tenesmus  of  dysentery.  This  sensation 
is  sometimes  more  distressing  than  any  other  symptom,  and  obliges 
the  patient  to  desist  from  walking. 

Leucorrhosa. 

Leucorrhoea  is  one  of  the  symptoms  usually  relied  upon  as  an  evi- 
dence of  disease  of  the  uterus.  In  the  healthy  condition  of  the  uterus 
and  vagina  there  ought  to  be  no  discharge ;  the  vaginal  canal  is 
merely  moist,  and  no  mucus  should  make  its  appearance  externally. 
When  the  mucous  membrane  is  temporarily  excited,  there  is  more 
than  ordinary  secretion ;  but  it  ceases  as  soon  as  the  cause  of  excite- 
ment passes. 

We  should  a  priori  expect  increased  vaginal  discharge  to  be  ac- 


372  LOCAL   SYMPTOMS. 

companied  Trith  some  form  of  disease,  especially  when  it  continaes 
for  more  than  a  few  days.  Our  knowledge  of  the  discharge  from 
mucous  membranes  lining  the  cavities  elsewhere  will  afford  us  enough 
data  to  confirm  these  views.  We  do  not  expect  to  see  a  constant  flow, 
however  moderate  it  may  be,  from  the  male  urethra  when  it  is  per- 
fectly healthy  ;  and  we  take  gleet  as  an  evidence  of  chronic  urethritis, 
and  it  is  generally  the  sequence  of  an  acute  attack  of  that  disease.  A 
constant  discharge  from  the  nose  is  an  evidence  also  of  more  or  less 
disease.  It  is  just  so  with  the  vagina.  The  indications  from  leucor- 
rhoea  are  derived  from  the  color  or  consistence  of  the  discharge,  or 
both.  The  discharge  from  the  vagina,  resulting  from  mere  excite- 
ment of  the  vaginal  crypts,  is  thin,  glairy,  and  not  very  tenacious. 
It  is  ordinarily  acid  in  reaction.  There  is  no  color,  and  but  little 
consistence  to  it.  When  a  moderate  excitement  of  the  internal  mu- 
cous membrane  of  the  neck  of  the  uterus  produces  a  discharge  of 
mucus,  sufficient  to  apj^ear  at  the  orifice  of  the  vagina,  the  discharge 
is  white,  not  unlike  milk,  and  when  examined  closely,  will  be  found 
to  consist  of  minute  coagula  swimming  in  a  little  clear  fluid.  "When 
the  mucus  flows  from  the  mouth  of  the  uterus  it  is  thick,  and  resem- 
bles very  closely  the  albumen  of  an  egg,  and  is  alkaline  in  reaction. 
When  it  passes  into  the  vaginal  canal,  it  meets  with  the  acidity  of 
the  vagina  and  is  coagulated,  and  the  whole  changed  from  a  colorless 
translucency  to  an  opaque  white.  The  reason  that  the  coagula  are 
small  and  so  numerous  may  j)robably  be  found  in  the  fact  that  the 
mucus  arrives  in  the  vagina  in  such  small  quantities ;  each  coagulum 
represents  a  minute  drop  of  mucus,  changed  in  quality.  As,  how- 
ever, the  mucous  membrane  of  the  vagina  furnishes  only  a  small 
quantity  of  acidity,  when  this  alkaline  discharge  from  the  cervix  is 
copious  it  soon  neutralizes  the  vaginal  acid,  and  passing  through  this 
canity  unchanged,  appears  at  the  external  parts  possessing  its  charac- 
teristic qualities.  We  then  hear  the  patient  complain  of  a  tenacious 
albuminous  leucorrhoea;  she  will  nearly  always  compare  it  to  the 
white  of  an  egg,  but  state  that  it  is  more  tenacious.  Unless  the 
quantity  is  considerable,  the  mucus  from  the  internal  cervical  mem- 
brane does  not  appear  at  the  external  orifice  unchanged,  but  passes 
into  this  curdled  condition.  There  is  often  a  considerable  quantity 
of  this  creamlike  leucorrhoea  in  the  whole  length  of  the  vagina,  and 
hence  it  has  been  supposed  by  many  that  this  is  the  vaginal  mucus 
in  its  natural  condition,  and  they  have  called  it  vaginal  leucorrhoea. 

Amount  of  Leucorrhoea  not  always  Proportioned  to  Extent  of  Disease. 

The  abundance  of  this  discharge  is  no  criterion  by  which  to  judge 
of  the  amount  of  disease  or  its  intensity,  but  it  will  scarcely  remain 
colorless  after  the  integrity  of  the  membrane  is  invaded.     When  the 


BEARING    DOWN    NOT   ALWAYS    CAUSED    BY    DISPLACEMENTS.       373 

albuminous  fluid  appears  at  the  orifice  of  the  vagina,  there  is  per- 
sistent cervical  disease  almost  of  a  certainty. 

Yellow  Lencorrhcea,  when  there  is  Abrasion  or  Ulceration. 

The  thick,  white,  or  egg-like  albumen  will  be  mixed,  when  there 
is  ulceration  in  the  cervix,  to  a  greater  or  less  extent,  with  pus,  so 
that  it  will  be  stained  yellow;  if  the  quantity  of  ulceration  is  consid- 
erable and  its  surface  is  producing  pus,  the  yellow  will  preponderate 
in  the  color,  and  sometimes  the  whole  of  the  production  becomes  yel- 
low. The  yellow  color  may  be  in  streaks  through  it,  or  intimately 
mixed  with  it,  so  as  to  stain  it  uniformly ,  or  the  pus  may  be  mixed 
with  the  white,  creamy  secretion  found  in  the  vagina.  Pus  may  be 
mixed  with  any  of  the  varieties  of  leucorrhcea,  and  impart  to  it  its 
tint  more  or  less  completely. 

Hoio  is  the  Pain  Produced  f 

How  are  the  local,  painful  symptoms  produced?  Is  the  pain  in 
the  groin  or  ilium  caused  by  prolapsus,  and  traction  on  the  broad  or 
round  ligaments?  I  think  not.  Pain  and  sensitiveness  in  the  ilium 
are  so  frequently  present — when  I  cannot  detect  any  kind  of  displace- 
ment, and  so  generally  disappear  when  the  inflammation  or  conges- 
tion is  cured— that  I  am  convinced  displacement  is  not  necessary  for 
their  production.  They  are  of  that  character  of  pains  which  range 
themselves  in  the  category  of  the  vague,  yet  indispensable  term,  sym- 
pathetic, or,  of  the  not  less  fashionable,  yet  equally  indefinite  term, 
reflex;  and  are  perhaps  in  the  ovary. 

Bearing  Down  not  always  Caused  by  Displacements. 

The  sense  of  weight  or  bearing  down  in  the  pelvis  is  one  about 
which  there  would,  from  its  nature,  seem  to  be  no  doubt  as  to  its 
origin  being  in  displacement.  It  gives  the  j^atient  the  idea  that  the 
womb  is  bearing  with  unusual  weight  on  unusual  places,  viz.,  the 
perineum,  the  rectum,  or  the  bladder;  and  yet,  in  a  great  many  in- 
stances, we  shall  fail  to  detect  any  deviation  from  the  natural  position 
of  that  organ ;  and,  as  soon  as  the  inflammation  is  cured,  the  symp- 
tom vanishes  without  any  treatment  with  reference  to  displacement. 
How  can  we  account  for  this  symptom?  I  think  its  explanation 
may  be  found  in  the  fact  that  the  pelvic  organs,  on  account  of  the 
general  pelvic,  vascular  turgescence,  are  unusually  sensitive  and  re- 
ceive painful  impressions  from  contact,  which  in  the  absence  of  these 
conditions,  would  have  no  efi'ect  in  causing  inconvenience  of  any  kind. 
Moderate  prolapse,  retroversion,  or  other  displacement,  when  unat- 
tended by  congestion  or  inflammation,  may  exist  for  a  long  time  with- 
out giving  rise  to  any  disagreeable  sensation  whatever.     When  the 


374  LOCAL   SYMPTOMS. 

uterus  is  slightly  displaced,  with  considerable  pain  and  sense  of  weight 
accompanying  this  condition,  the  displacement  is  commonly  considered 
to  be  the  cause  of  the  distress.  When,  however,  the  uterus  occupies 
a  normal  position,  and  a  sense  of  weight  and  pain  still  exists,  it  is 
regarded  by  most  practitioners  as  the  result  of  an  "irritable  uterus." 
That  the  uterus  is  sensitive,  "irritable,"  if  the  term  suits  better,  there 
is  no  doubt;  but  that  it  is  ever  so  without  congestion  or  inflammation 
I  do  not  believe. 

Severity  of  Suffering  not  Commensurate  with  Amount  of  Disease. 

The  great  error  in  the  estimate  of  the  importance  of  uterine  inflam- 
mation is  in  endeavoring  to  measure  the  amount  of  inflammation  by 
the  severity  of  suffering,  in  assuming  that  because  the  woman  suffers 
a  great  deal  there  must  necessarily  be  extensive  inflammation  or 
ulceration..  I  believe  I  have  seen  more  nervous  prostration,  more 
keen  suffering,  and  have  heard  louder  complaints  from  a  small  amount 
of  endocervicitis  than  from  extensive  and  obvious  external  ulceration. 
Pelvic  congestion  and  increased  sensitiveness  of  the  viscera  contained 
in  the  pelvic  cavity,  caused  by  a  small  amount  of  persistent  inflam- 
mation in  the  neck  of  the  uterus,  calls  into  action,  in  an  exaggerated 
and  intensified  form,  all  the  sympathies  which  are  excited  by  the 
uterus  in  its  physiologically  congested  condition,  and  its  persistence 
wears  the  more  upon  the  general  organism  on  account  of  the  increased 
sensitiveness  produced  from  day  to  day  by  virtue  of  its  chronicity 
alone.  It  is  anticipating  what  I  shall  say  in  the  chapter  on  Prognosis, 
to  state  that  endocervicitis  is  not  only  more  difficult  to  cure,  but  more 
destructive  to  the  health  and  happiness  of  the  patient  than  inflamma- 
tion and  ulceration  external  to  the  os.  Indeed,  we  often  find  cases  of 
extensive  ulceration  very  apparent  through  the  speculum,  and  conse- 
quently entirely  unmistakable  to  the  most  careless  observer,  which 
produces  less  inconvenience  than  an  amount  of  endocervicitis  so  small 
as  to  escape  the  attention  of  any  but  an  experienced  gynecologist. 
This  fact  is  perplexing,  but  the  knowledge  of  it  will  cause  a  proper 
appreciation  of  what  is  apparently  a  trifling  matter. 

Effects  on  the  Functions  of  the  Uterus. 

Having  given  the  foregoing  sketch  of  the  general  and  local  symp- 
toms of  congestion  and  inflammation  of  the  uterus,  I  purpose  to 
glance  at  the  effects  produced  on  the  functional  action  of  that  organ. 
The  first  function  assumed  by  the  uterus  and  the  last  it  continues  is 
menstruation.  It  becomes  a  matter  of  interest  to  the  physician  to 
ascertain  the  cause  of  deviations  in  a  function  so  persistent,  so  general, 
and  so  important  to  the  health  of  woman.  As  hyperemia  is  the 
cause  of  injurious  and  even  destructive  tissual  changes  and  of  func- 


EFFECTS  OF  PARTIAL  CLOSUEE  OF  OS  UTERI  ON  MENSTRUATION.    375 

tional  aberrations  in  the  vital  organs  much  more  frequently  than  any 
other  pathological  condition,  so  I  think  that  the  functional  aberra- 
tions of  the  uterus  particularly  depend  much  more  frequently  upon 
it  than  upon  any  other  cause. 

Pain  during  Menstruation. 

Pain  during  menstruation  is  not  necessarily  attended  by  deviation 
from  the  normal  monthly  flow.  That  there  are  varieties  of  dysmen- 
orrhoea  or  painful  menstruation,  with  unusual  quantities  and  extra- 
ordinary kinds  of  discharge,  is  true ;  but,  in  many  instances,  the 
discharge,  though  accompanied  with  pain,  is  right  as  to  its  character 
and  quantity. 

Kind  of  Pain  attendant  upon  Uterine  Inflammation. 

The  kind  of  pain  attendant  Upon  uterine  inflammation  is,  for  the 
most  part,  the  same  in  quality,  but  varying  in  intensity.  It  is  a  con- 
tinuous sore  pain,  with  heat  in  the  parts,  sometimes  so  slight  as  to 
give  the  patient  very  little  inconvenience,  and  it  varies  from  this  to 
pain  of  great  severity.  The  pain  is  at  times  sufficient  to  cause  the 
patient  to  keep  her  bed  for  several  clays,  and  sometimes  for  the  whole 
period  of  the  menstrual  flow;  occasionally  it  amounts  to  agony,  pros- 
trating her  by  a  paroxysm  which  may  last  for  hours,  or  even  several 
days. 

Cramping  Pain. 

Instead  of  this  continuous  sort  of  pain,  of  varying  intensity  and 
duration,  there  are  less  frequently  painful  throes  "  coming  and  going," 
like  labor-pains  or  after-pains.  This  kind  of  pain  is  often  mistaken 
for  colic.  They  are  often  very  severe,  and  may  last  a  few  hours  or 
several  claj^s.  They  may  depend  on  some  substance  contained  in  the 
uterus,  as  shreds  or  membranes  of  fibrous  exudation,  and  cease  at 
their  expulsion.  But  oftener  no  such  cause  can  be  discovered  in  the 
evacuations ;  nothing  can  be  found  but  fluid  blood,  or  coagula  evi- 
dently formed  in  the  vagina.  In  other  cases  the  os  uteri  internum  is 
small,  and  does  not  readily  admit  the  passage  of  the  uterine  sound. 

Effects  of  Partial  Closure  of  the  Os  Uteri  on  Menstruation. 

Many  practitioners  believe  that  this  condition  of  the  os  internum, 
by  preventing  the  ready  flow  of  the  blood,  causes  it  to  accumulate 
until  the  quantity  is  sufficient  to  arouse  expulsive  efforts  for  its  ex- 
trusion. In  a  large  majority  of  cases  I  have  had  the  opportunity  of 
observing,  there  was  no  coarctation ;  and  in  several  of  the  worst  cases 
I  have  met  with,  the  os  internum  allowed  the  sound  to  pass  with  so 
much  freedom  that  I  could  not  distinguish  its  locality.     It  is  also  true 


376  LOCAL,  SYMPTOMS. 

that  in  many  cases  in  which  the  os  externum  was  not  larger  than  a 
small  pinhole,  the  patients  menstruated  without  any  pain  whatever. 
By  far  the  most  frequent  causes  of  dysmenorrhcea  from  obstruction  I 
meet  with  are  in  connection  with  flexions  of  the  uterus.  I  can  easily 
understand  that  a  sharp  curvature  in  the  cervix,  or  at  the  junction, 
will  prevent  the  free  efflux  of  the  menstrual  fluid.  In  such  cases  the 
pains  resemble  labor-pains,  and  are,  doubtless,  of  the  character  of 
uterine  contractions.  The  pain  from  inflammation  may  occur  at  any 
time  during  the  menstrual  flow,  and  before  and  after  it.  Not  unfre- 
quently  a  paroxysm  of  severe  pain,  lasting  several  hours  or  a  day, 
warns  the  patient  of  the  approach  of  the  discharge,  and  subsides  sud- 
denly and  completely,  or  gradually  and  incompletely,  as  soon  as  the 
discharge  is  fairly  established.  Frequently  the  pain  continues  during 
the  whole  time  of  menstruation,  beginning  shortly  before  or  synchro- 
nous with  the  discharge,  and  subsiding  with  it,  though  in  occasional 
cases  it  continues  after  it.  We  sometimes  meet  with  patients  who 
begin  to  menstruate  without  any  suffering,  but  who  have  pain  during 
the  flow,  or  after  its  discontinuance.  I  think  that  a  majority  of 
patients  affected  with  uterine  disease  have  some  pain  during  menstrua- 
tion ;  but  there  are  some  who  have  none  whatever,  and  pass  through 
their  period  with  little  or  no  suffering. 

Manner  of  the  Flow  modified  by  Inflammation  and  Congestion. 

The  manner  of  the  flow  is  often  modified.  Instead  of  the  continu- 
ous flow,  commencing  moderately,  gradually  increasing,  and  then  as 
gradually  declining,  every  manner  of  deviation  almost  may  exist. 
With  some,  the  discharge  begins  naturally,  increases  very  rapidly, 
until  at  the  end  of  twenty-four  or  thirty-six  hours  an  average  amount 
is  lost,  and  then  the  discharge  suddenly  declines  and  ceases,  or  con- 
tinues in  very  moderate  quantity  for  a  time  longer,  and  gradually  or 
suddenly  stops.  With  others,  the  flow  may  begin  and  proceed  natu- 
rally for  a  day  or  two,  cease  for  one  or  two  days,  and  then  reappear 
and  flow  freely  for  a  sufficient  time.  When  menstruation  proceeds  in 
this  way,  it  is  generally  attended  with  pain.  These  two  varieties  are 
more  frequent  than  any  other. 

Duration  of  the  Floiv. 

The  duration  of  the  flow  may  not  be  affected  by  it.  The  flow  may 
continue  three  weeks  or  the  whole  month.  This,  however,  is  not 
frequent.  It  does  not  much  affect  the  jjeriodicity  of  return,  of  men- 
strual congestion  and  effort ;  but  it  is  not  unusually  the  case  that  we 
cannot  distinguish  the  discharge  which  attends  ovulation  from  the 
hemorrhage  which  proceeds  from  an  ulcerated  surface,  as  hemor- 
rhagic  congestion  is   so   constantly   present.     We   often  meet  with 


MENORRHAGIA   AND   AMENORRHCEA.  377 

patients  who  are  so  confused  by  the  frequent  irregular  returns  of 
uterine  hemorrhage  that  they  lose  all  reckoning  as  to  the  time  for  the 
menstrual  return.  Occasionally,  continuous  hemorrhage  is  present. 
The  most  frequent  deviation  from  regularity  in  menstruation  consists 
in  a  slight  anticipation  of  the  time  of  its  return. 

Menorrhagia. 

Menorrhagia,  or  hemorrhage  at  the  menstrual  period,  is  not  an 
unusual  functional  deviation.  The  hemorrhage  is  often  very  consid- 
erable and  continues  after  the  usual  period  has  passed  by.  The 
flooding  is  usually  greater  while  the  patient  is  in  an  erect  posture, 
and  it  is  greatly  moderated  by  recumbency.  Occasionally,  however, 
it  is  not  moderated  by  this  means.  It  would  seem  probable,  a  priori, 
that  menorrhagia  would  be  the  rule  with  patients  affected  with  uter- 
ine inflammation,  but  such  is  not  the  case.  I  am  not  sure  that  even 
a  majority  of  patients  have  it. 

Menorrhagia  frequent  in  Endo cervicitis. 

I  have  observed  that  menorrhagia  occurs  much  more  frequently  in 
patients  when  the  inflammation  occupies  the  cavity  of  the  neck;  this 
also  is  the  case  with  painful  menstruation.  All  cases  in  which  there 
has  been  either  great  pain  or  hemorrhage,  or  both,  for  they  are  fre- 
quently coexistent,  have  been,  in  my  observation,  cases  in  which 
endocervicitis  is  the  principal  disease.  Menorrhagia  is  not  always  the 
result  of  inflammation  of  the  uterus,  though  inflammation  is  its  most 
frequent  cause ;  and  in  such  cases  it  cannot  be  cured  without  first 
curing  the  inflammation. 

Amenorrhoea  sometimes  Results. 

Amenorrhoea  is  the  least  frequent  of  menstrual  deviations  as  the 
effect  of  inflammation  or  congestion  of  the  uterus ;  but  this  inflam- 
mation is  frequently  the  cause  of  scanty  menstruation.  It  is  curious 
to  note  the  manner  in  which  this  scantiness  occurs.  It  seems  to  come 
on  after  the  inflammation  has  lasted  for  a  considerable  time,  and  is 
almost  always  associated  with  sterility.  In  cases  I  have  watched  for 
some  time,  the  organ  was  atroi^hied  and  rendered  less  vascular  and 
erectile ;  probably  on  account  of  a  deposition  of  fibrin  throughout 
the  general  structures  of  the  uterus.  The  scantiness  is  sometimes 
attended  with  irregularity,  which  consists  in  postponement  or  length- 
ened intervals.  I  treated  one  patient  for  endocervical  metritis,  in 
whom  the  uterus  did  not  appear  to  be,  as  far  as  I  could  measure  it 
per  vaginam,  more  than  one  inch  and  a  half  in  length,  and  corre- 
spondingly small  in  the  other  dimensions.  This  patient  would  men- 
struate sometimes  only  a  day  every  month,  and  discharge  but  half  an 


378  LOCAL   SYMPTOxMS. 

ounce  of  blood  each  time,  and  occasionally  the  discharge  would  not 
return  for  five,  six,  and  even  nine  months.  In  early  life  her  menses 
had  been  regular  in  quantity^  quality,  and  times,  and  unattended 
with  pain.  She  was  barren,  having  never  conceived,  as  far  as  she 
was  aware.  She  dated  the  beginning  of  her  disease  from  vaginitis 
during  an  attack  of  fever,  which  occurred  two  or  three  months  after 
marriage. 

Function  of  Generation  affected  by  It.  ■ 

The  great  function  for  which  the  uterus  was  formed,  that  of  gen- 
eration, seems  very  frequently  to  be  disturbed  by  inflammation  of 
the  neck  of  the  uterus.  Some  practitioners  think,  because  a  woman 
bears  children  with  frequency,  the  uterus  cannot  be  much  diseased. 
This  is  unquestionably  a  mistake.  I  have  known  many  women  with 
extensive  ulceration  to  bear  children  very  frequently,  but  there  is 
always  great  liability  to  embarrassment  of  the  function  in  such  cases. 
Conception  may  be  entirely  prevented  by  inflammation,  or  gestation 
may  be  arrested  by  miscarriage,  or  labor  may  be  rendered  difiicult  by 
it ;  and  there  is  no  doubt  that  many  cases  of  sterility  depend  wholly 
upon  inflammator}'  action  about  the  neck. 

Sterility. 

Sterility  is  attended  by  different  circumstances.  Some  women  are 
sterile  their  whole  lifetime ;  others,  after  having  borne  children  to 
the  full  period  and  given  birth  to  them,  become  sterile  for  years,  or 
for  the  whole  of  their  subsequent  life  ;  others  again  become  pregnant 
soon  after  marriage,  miscarry  at  an  early  period,  and  never  again  con- 
ceive. In  many  cases  of  sterility  which  I  have  had  the  opportunity 
of  examining,  I  have  found  evidence  of  inflammation  in  the  cervical 
cavity.  Very  often  the  inflammation  is  confined  to  this  cavity.  The 
history  of  these  cases  showed  that  congestion  and  inflammation  had 
existed  from  the  time  of  menstruation;  these  were  cases  in  which 
conception  had  never  taken  place.  In  cases  of  sterility  in  which 
the  women  have  become  sterile  after  having  once  borne  children, 
ulceration  is  usually  situated  around  the  os,  extending  upward  into 
the  cavity  of  the  neck.  This  is  almost  certain  to  be  the  case  if  the 
woman  has  borne  several  children.  When  the  patient  has  miscarried 
but  once,  there  is  not  likely  to  be  external  inflammation  to  any  great 
extent ;  but  if  there  have  been  several  abortions,  the  ulceration  is  apt 
to  creep  out  and  manifest  itself  upon  the  labia  uteri,  and  sometimes 
becomes  very  extensive.  Although  the  foregoing  statements,  with 
reference  to  the  position  and  extent  of  ulceration  in  sterility,  will 
generally  be  found  to  correspond  with  the  appearances,  yet  we  must 
not  be  surprised  to  find  pretty  extensive  ulceration  external  to  the  os 
uteri  in  the  originally  sterile  j)atient ;  and  in  those  who  have  borne 


CONDITIONS    OF    THE    UTERUS    IN    ABORTION.  379 

children  and  become  sterile  afterward,  we  shall  sometimes  find  no 
external  ulceration.  The  result  of  my  observation  is,  that  when 
sterility  originates  in  uterine  inflammation,  it  is  in  that  form  of  it 
known  as  endocervicitis.  Sterility  often  depends  on  the  condition 
and  quality  of  the  leucorrhoea.  In  many  of  these  cases  the  secre- 
tions from  the  vagina  are  very  abundant  and  intensely  acid,  so  as  to 
produce  irritation  of  the  external  organs.  Although  the  semen  is 
diluted  and  defended  from  the  influence  of  acid  vaginal  secretions, 
by  mucus  of  alkaline  reaction,  yet  when  these  vaginal  secretions  are 
abundant  and  possess  strong  chemical  qualities,  they  may  destroy 
the  vitalizing  influence  of  the  seminal  fluid,  and  thus  prevent  fructi- 
fication. Or  the  very  thick,  tenacious,  albuminous  fluid,  which  some- 
times plugs  up  the  OS  uteri  and  whole  cervical  cavity,  may  prevent 
the  ingress  of  the  spermatozoa,  which,  by  their  independent  motion, 
according  to  present  belief,  penetrate  the  uterus,  meet  the  ovum 
somewhere  on  its  passage  to  the  os  uteri,  and  produce  their  fructifying 
influence  upon  it ;  and  thus  is  precluded  the  possibility  of  efi'ective 
insemination. 

Abortion. 

But  conception  may  readily  occur  and  pregnancy  be  complete,  and 
after  gestation  has  continued  for  a  certain  time  abortion  may  take 
place.  Abortion  is  a  very  frequent  effect  of  inflammation  and  ulcera- 
tion of  the  OS  and  cervix  uteri.  The  seat  of  inflammation  or  ulcera- 
'tion  which  most  frequently  induces  it  is  inside  the  cervical  cavity. 
We  find  some  patients  who  have  aborted  very  frequently  and  never 
had  a  full-term  child ;  others,  who  have  had  one  or  more  children, 
but  who  miscarry  every  pregnancy  afterward ;  and  again,  others  who 
miscarry  frequently  and  occasionally  go  to  full  term.  It  is  not  strange 
that  miscarriages  should  result  from  this  cause ;  a  -priori,  miscarriage 
might  be  regarded  as  its  necessary  effect.  Nevertheless,  many  patients 
bear  children  at  term  who  labor  under  severe  ulceration,  and  who  are 
prostrated  by  the  constitutional  sympathies  accompanying  pregnancy. 

Conditions  of  the  Uterus  in  Abortion. 

Two  general  conditions  of  the  uterus  exist  as  the  efi'ect  of  cervical 
inflammation,  and  are  probably  the  proximate  causes  of  abortion,  viz., 
congestion  or  arterial  injection  of  sufficient  strength  to  cause  hemor- 
rhage ;  and,  perhaps,  by  means  of  insinuation  of  the  clots,  separation 
of  the  placenta,  or  irritability  of  such  a  nature  occurs  that  contraction 
and  expulsion  follow  conception ;  or,  perhaps  increased  sensitiveness 
of  the  mucous  membrane  may  increase  its  excito-reflex  influence  so 
as  to  arouse  uterine  contraction,  and  thus  cause  the  foetus  and  mem- 
branes to  be  expelled.  When  abortion  is  caused  by  congestion,  it  is 
apt  to  be  ushered  in  by  hemorrhage.     The  hemorrhage,  after  con- 


380  LOCAL   SYMPTOMS. 

tinning  for  a  varied  length  of  time,  from  a  few  honrs  to  several  clays, 
is  followed  by  uterine  contractions.  When  abortion  is  the  result  of 
increased  irritability,  the  first  symptom  is  contraction,  with  the  par- 
oxysmal pains  attendant  upon  it.  This  continues  for  a  time,  when 
hemorrhage  and  expulsion  succeed.  When  abortion  occurs  once,  it 
is  very  likely  to  recur  in  every  subsequent  pregnancy  about  the  same 
time,  until  the  disease  is  cured  upon  which  it  depends.  While  abor- 
tion is  very  apt  to  recur  in  the  congestive  or  hemorrhagic  variety,  it 
is  generally  not  so  exact  in  the  time  of  recurrence.  This  variety, 
however,  takes  place  more  frequently  at  the  time  when  the  monthly 
congestion  is  present,  while  the  other  is  independent  of  such  influence. 
The  probability  is,  that  in  the  congestive  variety  the  foetus  perishes 
before  expulsive  efforts  arise ;  while  in  the  other  the  foetus  is  not 
affected  until  the  contractions  have  continued  long  enough  to  parti- 
ally separate  the  placental  attachments.  Whatever  doubt,  however, 
may  exist  in  all  this,  there  can  be  no  question  as  to  the  injurious  effect 
produced  upon  gestation  by  ulceration  or  inflammation  of  the  cervix 
uteri.  Mr.  Whitehead,  of  Manchester,  England,  has  written  a  book, 
full  of  information,  almost  solely  to  illustrate  this  consequence  of 
uterine  inflammation. 

Effect  upon  Labor. 

The  effect  which  inflammation  of  the  uterus  exerts  upon  labor  is 
not  so  apparent  as  upon  the  progress  of  gestation.  Although  I  have 
watched  patients  whom  I  knew  to  be  laboring  under  inflammation 
of  the  neck  of  the  uterus  in  parturition,  I  have  not  been  able  to  per- 
ceive any  increase  in  suffering  or  tediousness. 

Even  when  induration  and  hypertrophy  were  both  of  several  years' 
standing,  no  ill  effects  from  them,  so  far  as  I  could  see,  attended  labor 
either  at  full  term  or  prematurely.  I  have  observed  cases  of  abortion 
occurring  in  such  patients  quite  as  readily,  and  with  as  few  trouble- 
some symptoms,  as  in  one  whose  uterus  was  healthy.  The  general 
tissual  changes  going  on  in  the  uterus  would  lead  us  to  expect  this 
in  advanced  j^regnancy,  but  I  confess  to  some  astonishment  at  having 
seen  kindl}^,  rapid,  and  complete  dilatation  in  abortion  at  the  early 
periods.  It  is  equally  singular  to  see  the  return  of  the  induration 
after  the  involution  of  the  uterus  is  fairly  completed.  One  would 
suppose  that  the  softening  accompanying  pregnancy  would  be  per- 
manent, and  this  is  usually  the  case.  I  have  not  observed  in  such 
cases  that  the  abortions  were  attended  with  more  hemorrhage,  or  were 
more  tedious  or  painful,  than  when  they  occur  as  the  result  of  some 
transient  cause. 

Effects  upon  the  Post-partum  Condition. 

Of  its  effects  upon  the  childbed  or  post-partum  condition,  a  favor- 
able opinion  cannot  be  given  from  my  observation.     A  good  getting- 


EFFECTS   UPON    THE    POST-PAETUM    CONDITION.  381 

up  is  not  to  be  expected  with  much  confidence  in  patients  affected 
with  uterine  disease.  The  most  common  effect  in  childbed  is  retard- 
ation of  the  processes  of  involution.  The  congestion  consequent  upon 
labor  is  protracted,  the  uterus  remains  larger  and  more  sensitive  than 
is  usual,  so  that  instead  of  the  organ  recurring  to  its  primitive  dimen- 
sions and  susceptibility  in  one  month,  two  or  more  may  be  required. 
The  lochia,  instead  of  subsiding  in  fourteen  or  twenty-one  days,  con- 
tinues for  weeks,  or  even  months,  after  it  should  have  subsided,  and 
when  it  goes  off  it  is  apt  to  merge  imperceptibly  into  leucorrhcea, 
which  becomes  persistent.  Inability  to  walk  or  stand  without  great 
distress  is  the  effect  of  the  size  and  sensitiveness  of  the  organ.  •  A 
sense  of  bearing  down,  or  of  weight  in  the  pelvis,  pain  in  the  sacrum, 
down  the  sciatic  nerve  or  in  the  hip,  harass  the  patient  greatly,  and 
these  symptoms  pass  off  so  slowly  that  she  is  kept  in  bed  an  unusual 
length  of  time.  Acute  metritis  not  unfrequently  supervenes,  or  acute 
inflammation  of  the  cellular  tissue  at  the  side  of  the  uterus.  Phlebitis, 
pyaemia,  and  phlegmatia  dolens  are  more  likely  to  arise  in  patients 
who  have  chronic  inflammation  of  the  cervix. 

On  the  other  hand,  it  is  a  fact  that  these  subsequent  acute  inflam- 
mations sometimes  operate  very  favorably  upon  the  chronic  affections. 
Instances  are  not  uncommon  of  patients  being  entirely  cured  by  the 
effects  of  gestation  and  labor  upon  the  tissue  of  the  neck  and  its 
mucous  membrane.  We  are  to  hope  for  this  favorable  result  only 
'  as  a  remote  probability,  because  as  already  stated,  the  condition  of 
the  parts  is  generally  left  in  statu  quo,  or,  if  any  difference  is  percep- 
tible, it  consists  in  an  aggravation  of  the  disease,  and  the  patients  get 
up  from  childbed  rather  worse  than  better. 


CHAPTER    XVIII. 

PATHOLOGY  OF  HYSTEEOPATHY. 

What  are  the  pathological  conditions  giving  rise  to  such  numerous 
and  diverse  symptoms  ? 

In  answering  this  question  it  should  be  remembered  that  in  con- 
sequence of  the  nervous  and  vascular  connections  and  the  one  great 
function  to  which  they  all  contribute,  physiologically  and  patholog- 
ically, the  pelvic  viscera  are  a  unit. 

From  the  ovaries  to  the  perineum  the  genital  organs  are  largely 
supplied  with  the  same  system  of  vessels  and  nerves,  and  are  presided 
over  by  the  same  genito-spinal  centre,  and  they  all  have  for  their  ob- 
ject the  same  general  purpose, — generation. 

In  ovulation,  menstruation,  concej)tion,  pregnancy,  parturition, 
lactation,  and  involution  they  all  participate,  and  are  in  a  continual 
state  of  change.  The  rectum  and  bladder  are  continually  influenced, 
physiologically  and  pathologically,  by  the  same  conditions,  and  in 
return  reflect  their  own  changes  back  upon  the  genital  organs  proper. 

All  the  genital  organs  are  thus  bound  together  as  one  great  and 
complete  system  set  ajjart  for  one  grand  purpose, — generation ;  sub- 
ject to  derangements  that  may  begin  in  any  one  part  or  organ,  and 
produce  disorder  in  all  the  rest.  Acting  as  a  whole  in  the  function 
of  generation,  this  extensive  and  perpetually  active  system  reacts  with 
great  energy  through  its  spinal  centre  upon  the  whole  organism. 

I  have  already  in  one  example  quoted  from  Dr.  Tyler  Smith— and 
similar  cases  are  continually  occurring — shown  how  vast  and  potent 
are  the  sympathetic  effects  produced  by  pregnancy  upon  the  system 
at  large. 

In  a  state  of  disease  this  great  system  is  as  powerful  in  causing 
morbid  symptoms  and  changes. 

This  view  of  the  comprehensive  nervous  and  vascular  interde- 
pendence of  the  pelvic  viscera,  and  their  united  influence  upon  the 
whole  body,  explains  how  the  disease  of  any  one  of  them  may  originate 
and  perpetuate  the  general  and  local  symptoms  enumerated  under  the 
terms  sympathetic  nervous  symptoms,  hystero-neuroses,  genito-uri- 
nary  neurasthenia,  etc.  And  we  are  obliged  to  give  full  scope  to  this 
idea  in  all  our  estimates  of  the  very  complex  functional  and  organic 
diseases  of  the  female  organs  of  generation,  if  we  would  arrive  at 
correct  indications  for  treatment. 

The  essential  pathological  conditions  of  the  pelvic  organs  upon 
which  the  reflex  sufferings  of  the  general  system  are  founded  are  the 


PATHOLOGY   OF   HYSTEROPATHY.  383 

hyperaemia  and  the  hypersesthesia  of  those  organs.  Without  increased 
sensitiveness  or  increased  vascularity  of  them  there  can  be  no  general 
suffering.  This  proposition  is  proven  by  the  testimony  of  the  best 
authors  and  teachers  everywhere. 

The  more  marked  form  of  hypersesthesia  is  for  the  most  part  con- 
fined to  the  urethra,  vulva,  jDerineum,  anus,  and  coccyx :  vaginismus, 
anal  fissure,  urethral  caruncula,  coccygodynia.  Sometimes  there  is 
hyperaesthesia  of  the  vagina  and  vaginal  cervix  uteri.  These  will  be 
described  in  their  proper  place. 

In  studying  the  subject  from  a  clinical  point  of  view  the  practi- 
tioner will  find  disease  of  the  ovaries  or  uterus  the  starting-point  of 
all  these  sympathetic  derangements  more  frequently  than  all  other 
pelvic  affections,  and  consequently  it  is  very  important  that  we  should 
have  a  clear  view  of  their  pathology. 

While  the  ovaries  in  many  respects  are  paramount  in  their  influ- 
ence on  the  pelvic  organs,  it  is  to  diseases  of  the  uterus  we  must  look 
for  an  explanation  of  the  great  majority  of  sympathetic  ailments 
above  described. 

Now  what  is  that  essential  pathological  condition  of  the  uterus 
which  causes  these  symptoms?  One  condition  seems  to  be  present 
more  frequently  than  any  other,  and  that  is  hypersemia.  The  enlarge- 
ment of  the  uterus,  as  well  as  the  hyperaesthesia  of  that  organ,  gen- 
erally depends  upon  hypersemia,  and  the  sympathetic  influences  of 
the  uterus  are  excited  through  the  system  of  nerves  that  accompany 
and  control  the  vascular  system, — the  vaso-motor  nervous  system. 
Displacements,  flexions,  and  lacerations  do  not  produce  any  general 
disturbance  except  when  attended  with  hypersemia.  This  statement 
is  made  in  a  direct  or  indirect  manner  by  almost  all  of  our  best 
gynecologists. 

Dr.  Emmet  says  :*  , 

"  A  version,  as  has  been  stated,  may  exist  for  an  indefinite  period  without  causing 
any  disturbance  so  long  as  the  organ  does  not  prolapse  sufficiently  to  increase  the  ex- 
isting obstruction  to  the  circulation." 

With  reference  to  lacerations  he  says : 

"Sometimes  the  laceration  heals  while  the  woman  remains  in  bed  after  labor,  but  if 
the  surfaces  should  not  heal  before  she  gets  up  they  will  soon  become  the  seat  of  exten- 
sive erosions,  which  bleed  readily.  As  the  uterus  increases  in  size  a  profuse  cervical 
leucorrhcea  follows,  and  the  appearance  of  a  frequent  show  causes  the  patient  to  seek 
relief.  She  will  complain  of  inability  to  stand  with  comfort,  of  a  continual  headache, 
witli  pains  down  her  limbs,  sometimes  irritation  of  the  bladder,  and  as  a  rule  marked 
nervous  disturbance." 


*  Principles  and  Practice  of  Gynecology,  pp.  309,  462, 


384  PATHOLOGY   OF   HYSTEROPATHY. 

And  again  on  page  467  : 

"The  uterus,  from  increased  weight,  and  while  resting  on  the  floor  of  the  pelvis, 
will,  by  traction  on  the  cellular  or  connective  tissue,  obstruct  the  circulation  sufficiently 
to  produce  not  only  increased  congestion  of  the  organ  itself,  but  also  of  the  neighboring 
tissue." 

These  quotations  show  that  Dr.  Emmet  believes  that  the  effects  of 
displacements  and  lacerations  are  to  produce  and  keep  up  hypersemia, 
congestion  of  the  uterus,  and  through  this  condition  to  cause  all  the  local 
and  general  symptoms. 

The  object  of  all  his  treatment  preparator}^  to  uniting  the  surfaces 
of  a  laceration  of  the  cervix  is  to  relieve  the  hyperaemia  by  giving  free- 
dom to  the  circulation  of  the  uterus  and  making  local  applications  to 
the  erosions.  When  all  of  this  is  done  the  symptoms  subside,  and  the 
cure  of  the  laceration  renders  the  cure  permanent, 

Hypersemia  is  not  often  an  independent  affection.  It  is,  in  fact,  gen- 
erally the  result  of  some  antecedent  etiological  lesion,  and  may  be 
removed  by  getting  rid  of  the  cause.  It  does,  however,  occasionally 
stand  independent  of  an}?-  other  lesion,  and  may  be  cured  by  measures 
having  no  other  object  in  view  than  the  removal  of  the  hypersemia. 

Now,  what  is  this  hyperemia?  There  are  undoubtedly  several 
forms.  1.  Active  hypertrophic  hypereemia,  as  in  pregnancy,  the  earlier 
conditions  of  subinvolution,  the  presence  of  fibrous  tumors,  or  granu- 
lar degeneration  of  the  mucous  membrane.  2.  Passive,  venous  or 
congestive  hypersemia,  as  where  the  uterus  is  displaced  or  flexed,  and 
the  blood  confined  to  the  fundus  or  other  portion  of  the  organ  by  con- 
striction of  the  veins,  or  where  effusions  around  the  uterus  prevent  the 
free  outward  flow  of  the  blood.  3.  Inflammatory  hyperjemia.  These 
are  the  most  common  and  easily-determined  forms,  and  will  serve  as 
examples  of  hypersemia.  All  these  forms  may  become  chronic,  and 
all  of  them,  when  of  chronic  duration,  produce  changes  in  the  fibrous 
structure  of  the  uterus. 

It  is  impossible  for  them  to  remain  simple  hypersemia,  because  the 
abundant  supply  of  arterial  blood  in  the  active  forms  of  congestion 
produces  hj'^pertrophy  of  some  of  the  tissues  that  enter  into  the  struct- 
ure of  the  walls  of  the  uterus,  and  in  others  give  rise  to  neoplasms. 

In  the  passive  and  inflammatory  forms  of  hypersemia  there  neces- 
sarily occur  fibrino-plastic  effusions,  which,  after  coagulating,  become 
organized  in  a  low  degree,  causing  not  hypertrophy,  but  induration 
and  condensation,  which  finally  cuts  off  the  capillary  circulation.  In 
these  cases  the  connective  tissue  formed  by  this  low  organization  of 
fibrino-plastic  effusion  supplants  the  natural  structure  of  the  uterus  to 
a  greater  or  less  degree,  and  is  what  I  understand  by  hyperplasia. 

After  the  uterus  is  thus  changed  in  structure  it  is  sometimes  impos- 
sible to  restore  it  to  its  natural  condition.     These  indurated  uteri  un- 


PATHOLOGY    OF    HYSTEEOPATHY.  385 

fortunately  are  not  deprived  of  their  sensitiveness ;  in  most  cases,  in 
fact,  there  is  hypersesthesia,  and,  as  a  consequence,  they  are  the  source 
of  extensive  reflex  mischief 

In  the  inflammatory  form  of  hypersemia  there  are  often  circum- 
scribed points  of  induration  in  the  cervix,  in  the  anterior  or  posterior 
walls  of  the  fundus,  owing  to  the  locality  in  which  the  vascularity  is 
most  protracted  or  intense. 

After  the  effusion  and  induration  is  established  the  active  inflam- 
matory condition  may  subside,  leaving  the  part  in  a  state  of  indura- 
tion and  hyperesthesia.  Thus  we  find  nodules  of  hardened  tissue,  not 
the  seat  of  inflammation,  but  the  consequence  of  that  process.  As  a 
rule,  these  nodules  may  be  removed  when  properly  treated,  especially 
if  they  exist  in  the  cervix.  The  deposits  thus  occurring  frequently 
distort  and  deform  the  cervix,  rendering  one  portion  more  prominent 
than  others. 

It  should  be  borne  in  mind  that  these  conditions  do  not  indicate  the 
presence  of  inflammation,  but  its  effects.  They  give  rise  to  the  same 
sympathetic  symptoms  and  suffering  that  are  noticed  in  other  forms 
of  uterine  disease. 

It  is  too  narrow  a  view  of  the  pathology  of  uterine  disease,  there- 
fore, to  apply  the  term  congestion  to  all  these  forms  of  hyperemia. 
To  complete  this  very  cursory  statement  in  reference  to  the  different 
forms  of  hyper£emia,  it  is  necessary  to  trace  somewhat  further  the 
changes  they  all  may,  and  generally  do,  bring  about.  During  the 
progress  of  all  these  hypersemise,  the  mucous  membrane  undergoes 
notable  changes.  One  of  these  changes  is  the  so-called  ulceration.  I 
use  this  phrase  "  so-called  "  in  imitation  of  those  who  deny  the  exist- 
ence of  ulceration. 

Now  ulcer  means  a  sore,  and  is  defined  by  Dunglison  to  be  "  a  so- 
lution of  continuity  in  the  soft  parts,  of  longer  or  shorter  duration." 

Is  a  solution  of  continuity  of  the  epithelium  an  ulcer  ?  Abra&ioni 
is  a  term  used  by  some  writers  to  signify  the  loss  of  epithelium  ;,  but, 
abrasion  means  a  solution  of  continuity  in  the  ei^ithelium,  and  is  es- 
sentially the  same  as  ulceration.  If  it  suits  the  reader  better  to  call 
this  loss  of  the  epithelium  abrasion,  I  have  no  objection  to  the  term, 
but  I  believe  it  less  a  reformation  in  nomenclature  than  a  dispute 
about  non-essentials. 

I  believe  further  that  abrasion  or  ulceration,  instead  of  being  an 
incident  resulting  directly  from  laceration,  is  an  essential  effect  of  the 
impaired  nutrition  of  the  mucous  membrane,  brought  about  by  the 
hyperffimic  condition  of  the  fibrous  structure  of  the  cervix. 

This  is  in  accordance  with  the  teachings  of  that  eminent  patholo- 
gist, the  late  Dr.  E.  R.  Peaslee,  in  the  lectures  delivered  to  his  classes, 
and  published  in  the  Medical  Record  for  January  and  February,  1'876,, 
and  most  of  the  recent  writers  on  gynecology. 

25 


386  PATHOLOGY    OF    HYSTEROPATHY. 

That  ulcerations  occur  in  the  trophic  forms  of  hypersemia,  we  have 
the  assurance  of  the  late  Dr.  Cazeaux,  who  found  that  a  large  number 
of  pregnant  uteri  were  ulcerated.     He  says  :* 

"According  to  MM.  Gosselin,  Danyau,  and  Costilhes,  'these  ulcerations  are  much 
less  frequent  than  I  had  supposed,  and  are  met  with  in  hardly  more  than  half  the 
cases,  while  I  have  observed  them  in  seven-eighths.'  In  short,  therefore,  tlie  fungous 
condition  of  the  neck,  and  the  ulcerations,  of  greater  or  less  depth,  which  complicate 
this  state  of  the  parts  near  the  termination  of  pregnancy,  seem  to  me  to  be  the  con- 
sequence of  the  active  or  passive  congestion  with  which  the  organ  is  affected." 

So  with  all  the  active  and  passive  congestions  the  integrity  of  the 
mucous  surface  of  the  cervix  is  affected,  and  it  is  the  seat  of  ulceration 
of  a  greater  or  less  depth. 

Now  then  I  think  we  must  regard  abrasions,  "  granular  and  cystic 
degeneration,"  or  ulcerations  of  the  cervix,  as  results  of  some  form  of 
uterine  hypergemia — trophic,  congestive,  or  inflammatory,  instead  of 
standing  as  an  etiological  condition. 

While  I  believe  the  hyjoeraemia  of  the  pelvic  organs  to  be  the  more 
frequent  form  of  disturbing  condition,  I  am  satisfied  that  there  are  a 
great  many  cases  of  pure  neurosis  of  the  genital  organs.  In  these 
cases  the  genetic  element  is  in  the  nervous  system,  and  the  manifesta- 
tions are  morbid  exaltations  of  the  sensibility  of  the  parts  in  which 
the  suffering  is  the  greatest.  There  is  no  congestion,  no  inflammation, 
no  displacement,  or  other  apparent  deviation  from  the  natural  appear- 
ances of  the  pelvic  viscera.  Yet  the  patient  has  pain  and  sensitive- 
ness in  one  or  all  of  them,  and  is  the  subject  of  the  most  distressing 
and  extensive  array  of  hystero-neuroses.  In  such  cases,  too,  there 
may  be  no  deviation  from  the  normal  condition  except  that  of  pain 
and  increased  sensitiveness.  They  are  not  always  even  dysmenor- 
rhoeal  cases.  Although  not  confined  to  multipara,  they  are  more  fre- 
quently found  in  young  girls  and  sterile  married  women.  In  consid- 
ering the  subject  of  the  essential  pathological  conditions  giving  rise  to 
uterine  symptoms,  we  cannot,  therefore,  ignore  the  neuropathic  forms 
of  ovarian  and  uterine  affections.  They  are  too  numerous  and  too 
obvious  to  escape  the  attention  of  the  observing  gynecologist. 

Mucous  Inflammation. 

As  a  simple  affection,  that  of  inflammation  of  the  mucous  tissue  is 
quite  frequent.  Where  it  coexists  with  inflammation  of  the  sub- 
mucous substance,  we  have  the  increase  of  size,  hardness,  and  irregu- 
larity of  shape  combined  with  the  evidence  of  mucous  disease. 

*  Pages  456-459,  fifth  American  from  seventh  French  edition. 


ENDOCERVICITIS.  387 

Seat  of  Mucous  Inflammation. 

The  inflammation  of  the  mucous  membrane  may  extend  from  the 
fundus  through  the  cavities  of  the  body  and  neck  to  the  os,  and  then 
cover  the  whole  of  the  vaginal  portion  of  the  uterus.  This  extent  of 
inflammation  is  not  very  frequent,  however,  and  when  it  occurs  it  al- 
most immediately  succeeds  parturition  or  abortion,  or  is  produced  by 
gonorrhoeal  inflammation.  I  have  seen  it  under  these  circumstances 
oftener  than  any  other.  It  almost  always  causes  a  great  deal  of  distress 
and  suffering. 

Probably  the  most  common  extension  of  inflammation  is  to  the  mu- 
cous membrane  of  the  cavity  of  the  cervix  and  body,  and  a  portion 
or  the  whole  of  the  membrane  covering  the  intralabial  portion  of  the 
OS.  By  far  the  greater  number  of  instances  that  have  come  under  my 
observation  in  practice  were  inflammation  of  the  membrane  around 
the  OS  and  inside  the  cavity  of  the  cervix.  I  fear  that  this  statement 
represents  a  fact  that  has  not  been  generally  apprehended  by  practi- 
tioners. I  am  disposed  to  believe  that  too  many  physicians  have 
failed  of  success  in  curing  their  cases  because  they  have  not  followed 
up  the  inflammation  sufficiently  in  the  cervix  above  the  os,  being 
satisfied  with  curing  that  which  was  visible  only,  and,  in  consequence, 
leaving  really  the  most  important  part  of  the  affection  untouched. 

Cavity  of  the  Body  of  the  Uterus. 

Inflammation  limited  to  the  cavity  of  the  body  of  the  uterus  is  not 
common,  but  I  am  quite  sure  that  I  have  met  with  it  in  several  in- 
stances. Some  of  these  had  been  treated  for  inflammation  of  the  os 
and  cervix,  and  cured  of  this,  but  the  inflammation  in  the  cavity  of 
the  body  was  left.  Others  had  not  had  any  treatment  for  uterine  dis- 
ease, so  far  as  I  could  learn.  They  had  habitual  leucorrhseal  discharge 
of  rusty-colored  mucus,  very  much  like  the  brickdust  sputa  of  pneu- 
monia ;  the  OS  externum  was  very  small,  and  the  os  internum  large, 
as  was  also  the  cavity  of  the  body. 

Endocervicitis. 

Endocervicitis  alone,  or  inflammation  limited  to  the  cavity  of  the 
cervix,  is,  on  the  other  hand,  an  extremely  common  form  of  the  dis- 
ease. Not  unfrequently  this  form  of  inflammation  exists  without  any 
appearance  of  it  in  the  os  or  external  to  it.  When  inflammation  of 
the  mucous  membrane  of  the  cavity  of  the  cervix  alone  exists,  it  has 
certain  effects  upon  the  shape  and  other  properties  of  the  neck  that 
are  apt  to  attract  our  attention.  Dr.  Bennett  describes  the  os  as  patent 
and  the  cavity  of  the  neck  enlarged,  so  as  to  admit  the  finger  and  per- 
mit the  opening  of  it  by  a  speculum  to  some  extent,  so  that  we  may 
see  the  inside.  Now,  while  this  is  very  generally  the  case,  it  certainly 
is  not  always  so.     This  open  condition  of  the  os  and  cervix  is  more 


388  PATHOLOGY   OF   HYSTEROPATHY. 

frequently  met  with  near  the  menstrual  periods  than  at  any  other 
time,  and  is  probably  always  owing  to  the  congestion  of  the  vascular 
tissue  of  the  cervix  and  about  the  os. 

Endocervicitis  with  Diminished  Size. 

I  have,  undoubtedly,  seen  many  cases  of  this  endocervicitis,  in 
which  neither  the  os  nor  cervical  cavity  was  in  the  least  enlarged, 
and  others,  in  which  the  os  uteri  was  contracted  much  below  its 
natural  size.  The  secretions  of  the  mucous  membrane  are  always 
modified  ;  generally  they  are  very  much  increased,  and  often  changed 
in  character.  They  may  become  purulent  or  sanguineous,  owing  to 
the  grade  of  the  inflammation  and  the  degree  of  congestion.  The  in- 
flammation situated  external  to  the  os,  on  the  end  of  the  uterus,  be- 
tween the  labia  or  their  external  surface,  is  very  common,  but  it  is  not 
often  limited  to  this  part.  It  is  almost  always  combined  with  endo- 
cervicitis. 

Special  forms  of  these  mucous  inflammations  are  found  more  fre- 
quently in  certain  sorts  of  patients. 

Endocervicitis  in  Virgins. 

Virgin  patients  seldom  have 'inflammation  external  to  the  os  uteri; 
their  disease  is  endocervicitis  almost  always ;  very  rarely  there  is  a 
little  rim  of  inflammation  around  the  os  upon  the  end  of  the  uterus. 

Endocervicitis  in  Aged  Women. 

Again,  in  senile  patients,  we  find  the  inflammation  in  the  cavity  of 
the-  cervix.  The  os  uteri  in  the  aged  is  normally  small,  and  simply 
looking  at  it  will  seldom  convey  a  correct  idea  of  the  state  of  the  cer- 
vical cavity,  but  the  introduction  of  the  probe  in  cases  of  endocervi- 
citis will  give  rise  to  very  great  pain.  The  endocervicitis  of  old  women 
is  extremely  difficult  to  manage,  and  is  always  protracted. 

External  Inflammation  combined  with  Internal  in  Childbearing 

Women. 

In  married,  childbearing  women  we  find  the  external  combined 
with  the  internal  uterine  inflammation  of  the  mucous  membrane. 
They  are  the  kind  of  patients  in  whom  most  frequently  the  enlarge- 
ments, indurations,  axid  fibro-cellular  inflammations  are  observed. 
The  form  of  disease  in  persons  who  have  been  married,  but  never 
have  been  pregnant,  partakes  to  some  extent  of  the  character  of  that 
of  the  virgin  and  the  childbearing  woman.  They  often  have  external 
combined  with  internal  mucous  inflammation,  but  not  often  fibro-cel- 
lular. Now,  what  I  mean  by  these  statements  is,  that  these  patients 
are  likely  to  have  the  forms  of  disease  which  I  have  ascribed  to  them, 
but  there  certainly  are  exceptions  to  all  of  them. 


CHAPTER    XIX. 

ETIOLOGY  OF  UTERINE  DISEASE. 

The  genital  apparatus  of  woman  is  in  a  constant  state  of  predis-. 
position  to  disease.  The  very  turgid  condition  of  these  organs  for  so 
many  days  in  every  month  is  one  that  in  appearance  borders  so 
closely  on  the  pathological  thai  in  other  organs  it  would  be  taken  for 
one  of  disease,  and  the  symptoms  are  equally  like  those  caused  by 
disease. 

This  similarity  between  menstrual  hypersemia  and  morbid  conges- 
tion is  so  great  that  it  makes  it  impossible  to  distinguish  the  differ- 
ence by  sight  and  touch  alone.  The  color  of  the  menstruating  uterus  is 
greatly  deepened ;  the  organ  is  larger,  heavier,  and  less  easily  moved 
in  the  pelvis,  and  we  know  that  it  requires  only  a  prolongation  of  this 
condition  to  constitute  a  state  of  disease.  Another  degree  of  nervous 
and  vascular  excitement  would  be  morbid  congestion  of  the  uterus, 
and  all  experience  shows  that  cold  applied  to  the  person  when  the 
organs  are  in  this  condition  seldom  fails  to  add  that  degree  of  excite- 
ment, or  that  the  same  thing  may  be  brought  about  by  standing  too 
much  or  by  other  unusual  exertion. 

The  position  of  the  genital  organs  at  the  lower  part  of  the  body, 
much  below  the  heart,  having  veins  without  valves  and  of  weak  con- 
tractile powers,  is  another  cause  of  exceptional  hypersemia. 

Add  to  these  the  frequent  erotic  excitement  to  which  they  are  sub- 
jected in  consequence  of  the  peculiar  sexual  life  a  woman  lives,  and 
we  have  another  predisposing  condition  of  great  influence. 

By  the  'peculiar  sexual  life  of  woman  I  mean  a  comparison  of  her 
life  with  the  sexual  life  of  other  animals. 

Female  animals  do  not  cohabit  night  and  day  the  year  round,  during 
pregnancy  and  nursing.  The  interval  between  the  acts  of  sexual  in- 
tercourse in  animals  is  long,  and  comprises  all  the  time  during  preg- 
nancy and  nursing,  while  women  observe  no  time  of  abstinence  except 
the  few  days  occupied  by  the  menstrual  flow,  labor,  and  the  period  of 
lying-in. 

Pregnancy  and  parturition  are  strongly  predisposing  conditions. 

The  long-continued  and  very  great  hypersemia  of  pregnancy  as  else- 
where shown  causes  abrasions  and  ulceration  before  labor,  while  the 
pressure  of  the  uterus  upon  the  bladder,  rectum,  etc.,  sometimes  gives 
rise  to  permanent  pelvic  difficulties. 

Parturition  is  so  generally  recognized  as  a  predisposing  cause  of 
disease  that  the  greatest  care  is  and  ought  to  be  taken  to  conduct  pa- 


390  ETIOLOGY   OF    UTERINE    DISEASE. 

tients  through  it  and  the  post-partum  condition  in  order  to  avoid 
subsequent  difficulties. 

Unusual  duration  of  labor  is  to  be  avoided  because  of  the  damage 
that  may  arise  from  too  long  pressure  by  the  child's  head  or  pros- 
tration of  the  nervous  system  from  violent  exertion.  But  in  the 
normal  labor  there  are  many  conditions  that  predispose  to  disease. 
The  uterus  is  left  large,  hypersemic,  and  in  a  state  of  degeneration, 
with  the  cervix  bruised,  lacerated,  and  denuded  of  its  mucous  mem- 
brane. 

The  vagina  and  all  of  its  surrounding  tissues  have  been  stretched, 
pressed,  and  bruised,  and  the  vulva  and  perineum  are  torn  and  bleed- 
ing. While  all  these  are  conditions  necessarily  attendant  upon  a 
natural  process,  and  consequently  must  be  regarded  as  normal,  yet 
they  are  certainly  upon  the  verge  of  disease,  and  are  predisposing 
conditions  prolific  of  disease.  They  predispose  to  acute  disease,  as 
metritis,  perimetritis,  cystitis,  vaginitis,  etc.,  but  their  influence  is 
more  frequently  observable  in  the  chronic  affections  resulting  from  an 
incomplete  recuperation  from  the  normal  accidents  of  labor. 

But  abortion  is  another  strongly  predisposing  as  well  as  exciting 
cause  to  disease  of  the  uterus.  In  many  cases  of  abortion  the  organ 
is  repaired  of  damages  as  well  as  after  natural  labor.  This,  how- 
ever, is  an  exception  to  the  general  rule.  Abortion  is  generally  fol- 
lowed by  either  acute  or  chronic  disease,  and  sometimes  both.  The 
reasons  for  this  are  too  obvious  to  require  any  farther  consideration. 

Other  and  very  grave  predisposing  causes  may  be  found  under  the 
head  of  puberty  and  change  of  life. 

■  In  a  state  of  predisposition  from  any  of  the  causes  above  mentioned, 
the  application  of  cold  is  often  productive  of  congestion  and  chronic 
inflammation  of  the  uterus  and  ovaries. 

This  is  often  proved  by  the  results  of  a  cold  during  the  congestion 
just  preceding  menstruation  or  at  the  time  of  the  flow,  and  in  child- 
bed, or  for  some  weeks  afterward. 

There  are  other  causes  which  act  in  conjunction  with  the  predis- 
posing conditions  I  have  mentioned  above,  but  are  sometimes  inde- 
pendent in  their  effects:  the  abuse  of  the  organs  by  the  practice  of 
vicious  habits,  masturbation,  excessive  intercourse,  etc.,  standing  too 
long,  working  the  sewing-machine,  and  the  pursuit  of  other  employ- 
ments that  keep  up  a  stasis  of  blood  in  the  pelvis.  School-teachers, 
sales-women  and  sewing-girls  come  within  the  influence  of  these 
causes. 

Still  other  causes  are  accidents,  violence,  gonorrhoea,  etc. 

Gonorrhoea  is  a  very  fruitful  source  of  chronic  endocervicitis  and 
endometritis.     Dr.  Emil  Noeggerath,*  of  New  York  city,  believes  that 

*  First  volume  Transactions  of  the  American  Gynecological  Society. 


ETIOLOGY   OF   UTEEINE   DISEASE.  391 

gonorrhoea  is  a  frequent  cause  of  several  forms  of  inflammation  in  the 
pelvic  organs  of  women,  as  of  the  Fallopian  tubes,  cellular  tissue, 
ovaries,  and  peritoneum.  He  finds  evidence  that  it  remains  in  a 
latent  condition  or  form  in  the  mucous  membrane,  and  in  consequence 
of  the  influence  of  some  exciting  cause  is  awakened  into  an  acute 
form  of  disease,  which  probably  more  frequently  attacks  the  pelvic 
peritoneum  or  cellular  tissue.  He  thinks  that  gonorrhoea  often  per- 
sists in  this  chronic  form  in  the  male,  and  although  apparently  cured, 
the  husband  is  capable  of  infecting  his  wife  for  years  afterward.  I 
am  quite  convinced  that  his  views  in  this  respect  are  not  without 
foundation  and  deserve  the  serious  consideration  of  the  profession. 
If  Dr.  Noeggerath's  teaching  should  be  demonstrated  by  further  obser- 
vation it  will  place  gonorrhoea  as  a  latent  source  of  mischief  on  the 
same  footing  as  syphilis.  However  this  may  be,  I  am  quite  sure  that 
chronic  endocervicitis,  in  which  the  glands  of  Naboth  are  the  princi- 
pal seat,  and  when  the  cervical  canal  is  filled  with  a  tenacious  mucus 
of  so  tough  a  consistency  as  to  make  it  difficult  to  remove,  is  fre- 
quently of  gonorrhoeal  origin. 

We  cannot  always  trace  these  chronic  cases  to  an  acute  attack  of 
gonorrhoea,  but  when  we  can  get  at  the  facts  we  will  generally  find 
that  the  husband  has  been  the  subject  of  gonorrhoea,  and  probably 
yet  has  gleet  or  the  chronic  form  of  that  disease. 

Under  the  head  of  puberty  I  have  pointed  out  many  deleterious 
influences  under  which  the  girls  of  this  country  are  placed,  and  which 
lead,  primarily  or  secondarily,  to  the  development  of  sexual  disease 
in  consequence  of  natural  and  social  conditions  which  cannot  be 
escaped. 


CHAPTER    XX. 

DIAGNOSIS  OF  UTERINE  DISEASE. 

Characteristic  Signs  of  Inflarfimation. 

The  signs  of  inflammation  of  the  submucous  tissue  or  substance  of 
the  neck  of  tiie  uterus  are,  increase  of  size,  tenderness,  and  generally 
hardness ;  of  the  mucous  membrane,  increased  color  and  secretion ;  of 
ulceration,  still  more  intense  redness,  purulent  discharge,  tenderness, 
and  not  much  enlargement.  The  former  conditions  may  be  ascer- 
tained by  the  touch,  the  latter  by  the  sight,  and  when  they  are 
mingled,  by  both  combined.  Open  external  abrasion  or  ulceration 
of  the  uterine  cervix,  after  the  parts  are  well  exposed,  and  cleared  of 
mucus  and  pus  by  wiping,  cannot  be  well  mistaken  or  overlooked ;  and 
the  practitioner  must  not  be  led  to  believe  the  case  one  of  no  impor- 
tance because  the  ulceration  is  not  very  .extensive.  This  raw  scarlet 
surface  is  always  indicative  of  mischief,  and  we  should  expect  any 
amount  of  suffering  from  even  a  small  patch  of  it. 

Diagnosis  of  Endocervicitis. 

There  are  cases  where  the  appearances  are  not  so  obvious,  where, 
in  fact,  all  the  parts  exposed  by  the  speculum  and  within  reach  of 
our  vision  have  a  natural  appearance.  No  redness,  rawness,  or  other 
discoloration  can  be  detected  on  the  neck,  in  the  mouth  of  the  uterus, 
nor  on  the  vaginal  surfaces ;  they  are  quite  healthy  in  appearance 
and  reality,  but  there  is  an  obvious  and,  in  many  instances,  a  copious 
secretion  of  tenacious  mucus  flowing  from  and  lying  in  the  os  uteri ; 
wipe  this  away  and  all  looks  right.  This  is  a  case  of  endocervicitis. 
In  some  instances  this  mucus  is  colored  with  streaks  of  yellow  by  the 
presence  of  pus,  or  it  is  wholly  yellow ;  here  there  is  loss  of  integrity 
in  the  epithelium  of  the  cervical  cavity.  The  mucous  membrane  in 
the  cervical  cavity  is  ulcerated.  If  we  remember  that  the  mucous 
membrane  secretes  only  enough  mucus  for  lubricating  purposes  in 
the  natural  condition,  we  can  arrive  at  no  other  conclusion  than  that 
the  membrane  is  in  a  state  of  hyperexcitement  when  its  secretion  is 
abundant  or  altered,  or  both.  When  we  see  mucus  in  even  small,  yet 
perceptible  quantities,  issuing  from  the  anus,  what  is  the  inference  ?  If 
this  is  abundant,  persistent,  and  colored  yellow,  however  healthy  the 
anus  might  appear  externally,  we  could  not  believe  that  the  rectum 
was  in  a  healthy  condition.  Why  not  then  positively  determine  that 
he  mucous  membrane  is  inflamed,  which  floods  the  os  uteri  with 


DIAGNOSIS   OF  UTEIIINE   INFLAMMATION.  393 

mucus  or  pus,  or  with  both?  If  we  introduce  the  probe  into  the 
cavity  of  the  cervix  thus  abundantly  secreting,  the  patient  will  nearly 
always  complain  that  we  touch  a  "  sore  place,  a  tender  spot,"  that  it 
hurts  her  in  her  back,  etc.  And  very  often  blood  will  immediately 
follow  the  withdrawal  of  the  instrument.  This,  however,  is  not  inva- 
riably the  case.  Another  diagnostic  evidence  of  endocervicitis  is  the 
increase  of  the  pain  ordinarily  experienced  by  the  patient  when  the 
probe  or  application  is  introduced. 

The  hypersecretion,  or  perverted  secretion  of  the  mucous  mem- 
brane, must  then  be  regarded  as  an  indication  of  disease  of  that  mem- 
brane. If  we  have  these  facts  fixed  in  our  mind,  and  if  we  act  upon 
them,  we  may  discover  and  cure  disease  that  w^ould  otherwise  escape 
our  attention  and  thwart  our  skill.  But  there  is  another  obvious  and 
common-sense  sign  of  inflammation  which  has  not  been  applied  in 
our  investigations  of  diseases  of  the  uterus,  viz.,  tenderness.  Tender- 
ness or  sensitiveness  to  the  touch  anywhere  else  leads  us  to  suspect 
inflammation,  but  in  the  uterus  it  is  unaccountably  set  down  as  indi- 
cating an  irritable  uterus  and  not  an  inflamed  one. 

Diagnosis  of  Submucous  Inflammation. 

I  think  when  I  touch  the  uterus  with  the  finger  or  an  instrument, 
and  the  patient  shrinks  from  the  contact  and  says  "  she  is  sore,"  or 
','  it  is  sore,"  that  there  is  inflammation  there.  Tenderness  is  not  an 
evidence  of  mucous  inflammation,  but  of  submucous  or  fibrous  in- 
flammation of  the  uterus. 

Complication  of  Mucous  with  Submucous  Inflammation. 

The  uterus  should  be  examined  by  the  same  diagnostic  rules  that 
govern  our  investigations  of  disease  in  other  organs.  Some  authors 
tell  us  that  ulceration  results  from  inflammation  of  the  submucous 
tissue,  and  others  that  the  inflammation  begins  in  the  mucous  mem- 
brane. However  this  may  be,  I  am  sure  that  inflammation  some- 
times exists  in  both  these  tissues  at  the  same  time.  In  this  case  we 
shall  have  tenderness  and  hypersecretion.  At  other  times  there  is 
submucous  without  mucous  inflammation;  then  we  shall  have  ten- 
derness without  hypersecretion.  Again,  we  may  have  mucous  with- 
out submucous  inflammation,  when  hypersecretion  without  tenderness 
will  indicate  it.  These  remarks  will  fix  the  importance  of  these  two 
symptoms  as  indicating  the  seat  of  the  disease. 

Size  of  the  Uterus  ordinarily  Increased — Exceptions. 

The  size  of  the  organ  is  one  indication  of  the  presence  or  absence 
of  inflammation ;  but  this  may  vary  very  much  under  what  would 
appear  to  be  the  same  form  of  disease.     In  endocervicitis  it  is  usual 


394  DIAGNOSIS   OF   UTERIXE   DISEASE. 

to  find  the  cervical  canal  increased  in  calibre ;  but  this  is  certainly 
not  always  the  case,  as  I  have  met  with  unmistakable  instances  in 
which  this  ca^'ity  was  decreased  in  size  and  the  os  uteri  almost  closed, 
it  being  so  small  as  to  admit  only  a  very  small  probe.  Where  there 
is  mucous  inflammation  of  the  cervix  extending  toward  the  cavity  of 
the  body,  and  more  particularly  where  the  disease  extends  into  the 
cavity  of  the  body,  the  whole  organ  is  likely  to  be  enlarged.  So  much 
enlargement  sometimes  takes  place  that  the  fundus  may  be  felt  con- 
siderably above  the  pubis.  Neither  is  this  always  the  case,  however ; 
often  there  is  no  enlargement.  The  hypertrophy,  or  general  enlarge- 
ment of  the  organ,  is  more  frequently  indicative  of  mucous  than  sub- 
mucous or  fibrous  inflammation. 

Atrophy  as  the  Result  of  Inflammation. 

In  fact,  I  think  that  long-continued  inflammation  of  the  substance 
of  the  body  and  cervix  often  brings  about  atrophy  or  shrinking  of  the 
uterus.  Permanent  increase  of  size  or  hardness  of  the  cervix  must  be 
the  result  of  submucous  inflammation,  and  generally  coexists  with  it. 

Almost  the  only  disease  with  which  chronic  inflammation  and  ulcer- 
ation of  the  cervix  uteri  are  likely  to  be  confounded,  is  cancer  in  some 
of  its  stages.  The  many  well-marked  symptoms  and  physical  condi- 
tions which  accompany  this  last  disease  are  now,  however,  so  well 
understood  and  so  thoroughly  described,  that  the  novice  need  not  be 
embarrassed  in  his  diagnosis  of  it. 

I  find  in  Becquerel's  Traite  CUnique  des  Maladies  de  Uterus,  pp.  320- 
323,  vol.  i.,  so  comj)lete  and  faithful  a  diagnostic  summary  between 
cancer  and  the  different  conditions  of  chronic  inflammation  of  the 
cervix,  that  I  have  translated  and  given  its  substance  for  the  conclud- 
ing portion  of  this  chapter.     It  is  subjoined  : 

Cancer  in  the  Scirrhous  Condition,  Inflammation  and  Ulceration. 

Cervix  hard,  unequal,  nodulated ;  os  not  Xeck   less  hard,  developed  regularly  in 

always    open,  sometimes    wrinkled  or  one  of  the  lips;  os  always  open, 
furrowed. 

Scirrhus  of  the  neck  often  implicates  the  The  induration   of   the   neck  never    ex- 
vagina,  tends  to  the  vagina.     Mobility  of  uterus 

complete. 

Hereditary  influence  is  often  traceable.  No  hereditary  influence. 

Touch  is  painless.  Touch  painful. 

Discharge  sometimes  absent ;    in  certain  Discharge  constant,  and  characterized  by 

cases  very  abundant,  and  consisting,  for  the    presence   of     transparent    mucus, 

the  most  part,  of  albuminous  serum.  muco-pus,  or  purulent  mucus. 

Menstruation    increased,    being     neither  Menstruation    more    painful,   often      re- 
more    nor    less    painful,    and    passing  tarded,  almost  always  scanty, 
often  into  the  state  of  real  hemorrhage. 

Absence    of   special    anaemia    when  the  Special  anemia,  as  above  described, 
vagina  and  body  of  the  uterus  are  in- 
volved.    Cancerous  cachexia. 


ATEOPHY   AS  THE  KESULT   OF   INFLAMMATION. 


395 


Cancer  in  the  Scirrhous  Condition.  Inflammation  and  Ulceration. 

Progress    continuous    and  without  cessa-  Often  stationary  for  a  long  time. 

tion. 

The  pain  in  cancer  is  very  sharp,  intense,  Pains  less  severe,  more  dull,  and  percep- 

and  lancinating,  and  not  influenced  by  tibly  influenced  by  walking  and  other 

locomotion  or  movements  of  any  kind.  sorts  of  motion. 


Ulcerated  State. 

Developed  at  the  critical  period  of  life 
generally. 

Preceded  and  accompanied  by  hemor- 
rhages. 

Severe,  sharp,  lancinating  pain. 

Development  essentially  in  sharp  irregu- 
larities and  nodosities. 

Adhesions  to  other  organs  as  soon  as  ul- 
ceration is  formed  ;  immobility  of  the 
uterus. 

The  surface  only  slightly  soft ;  subjacent 
tissue  scirrhous. 

Ulceration  deep,  unequal,  essentially  ir- 
regular, with  thick,  elevated,  and  hard 
edges. 

Always  granulations. 

Discharges  extremely  abundant,  consist- 
ing of  purulent  and  often  sanguineous 
serum  ;  nauseous  and  often  fetid  odor. 

Great  hemorrhage  from  time  to  time,  not 
necessarily  at  menstrual  period. 


Chronic  Inflammation  and  Softening. 
Occurs  earlier  in  life  almost  always. 

Not  preceded  by  hemorrhage. 

Pain  dull  and  profound. 

Enlargement    regular    and    rounded,   or 

regularly  lobulated. 
Complete   absence  of  adhesions  to  other 

organs.     Entire  mobility   of   the  neck 

and  body  of  the  uterus. 
Tissue  of  the  cervix  not  hard,  and  easily 

destroyed. 
When   ulcerations   exist,  less  deep,  with 

tumefied  edges. 

Granulation  often  accompanies  the  other 
lesions. 

Discharges  less  abundant,  consisting  of 
muco-pus  alone,  or  accompanied  with 
a  little  blood,  without  odor. 

Always  hemorrhage,  but  often  a  mere  pro- 
longation of  the  menstrual  discharge. 


Cancerous  Ulceration. 

Developed  upon  a  hypertrophied  and 
scirrhous  surface. 

Ulceration  deep,  vast,  unequal,  grayish 
surface,  with  thick  edges,  and  easily 
bleeding. 

Ulcerated  surface  hard,  presenting  numer- 
ous lobes  and  tubercles,  with  nodosities 
and  great  hardness. 

Often  great  loss  of  substance. 

Cervix  and  corpus  uteri  immovable,  on 
account  of  adhesions. 

Discharges  sanious,  fetid,  sanguinolent, 
and  of  an  insupportable  and  character- 
istic odor. 

Cancerous  cachexia  always  present. 


Simple   Ulceration. 

Ulceration  often  on  a  healthy  tissue,  or 
presenting  the  soft  or  hard  varieties  or 
inflammatory  injection. 

Ulceration  more  superficial,  the  edges 
less  developed,  and  more  regular  at 
the  bottom,  not  always  easily  made  to 
bleed. 

Nothing  of  the  sort  in  chronic  inflamma- 
tion and  ulceration. 

Ulceration  is  not  always  accompanied  with 

loss  of  substance. 
Neck  and  body  always  movable. 

Discharge  of  muco-pus,  or  purulent  mucus, 
always  more  or  less  abundant. 

Special  ansemia. 


396  DIAGNOSIS   OF   UTERINE   DISEASE. 

"  Professor  Otto  Spiegelberg,  speaking  of  the  difficulty  of  distingnishing  between 
simple  inflammatory  induration  of  the  cervix  uteri — hyperplasia — and  carcinomatous 
infiltration,  gives  the  following  as  a  certain  indication  of  cancerous  infiltration,  viz. : 
'A  'peculiar  induration  of  the  cervix,  the  disposition  of  its  mucous  membrane,  and  its  reaxition 
to  the  dilatation  of  sponge  tents.'     He  expounds  each  member  of  this  rule. 

"The  hardness  of  cancerous  deposit,  in  comparison  with  simple  induration,  is  well 
known ;  but  the  distinction  is  frequently  impossible  to  make  out,  even  by  the  most 
cultivated  touch.     The  two  other  symptoms  are  unequivocal,  and  are  as  follows : 

" '  First,  the  mucous  membrane  in  cancerous  growth  is  firmly  connected  with  the  un- 
derlying induration,  and  immovable  over  it,  which  is  not  the  cnse  in  mere  hyper- 
plastic thickening  and  induration ;  and,  second,  while  the  latter,  under  the  pressure 
of  compressed  sponge,  in  the  cervical  canal,  becomes  regularly  even,  though  at  times 
inconsiderably  looser,  softer,  and  thinner,  the  cancerous  infiltration  remains  unalter- 
ably hard  and  rigid,  and  cannot  be  stretched.'  He  goes  on  to  explain  the  reason  for 
this  difference  between  the  products  of  the  two  inflammations  from  the  locality  where 
the  cancerous  inflammation  originates,  which  is  the  utero-malpighii ;  or,  in  extremely 
rare  cases,  from  the  glands  of  the  cervical  canal.  The  latter  form  gives  rise  to  the  al- 
veolar or  colloid  form,  of  which  he  has  only  seen  one  case.  As  a  rule,  the  disease  is 
developed  from  the  interpapillary  depressions  of  the  epithelium.  According  as  the 
growth  of  the  epithelium  into  the  tissues  below  is  or  is  not  attended  by  a  simultaneous 
growth  of  the  papillae,  two  forms  of  cancer  may  be  distinguished, — the  papillary, 
villous,  or  cauliflower  excrescence,  and  the  simple  infiltrated  form."  —  Cincinnati 
Clinic  {from  Archivfiir  Gyncekologie). 


CHAPTER  XXL 

GENERAL  TREATMENT  OF  UTERINE  DISEASE. 

Main  Objects  of  General  Treatment 

The  main  object  to  be  gained  by  general  treatment  is  to  palliate  the 
general  condition  of  the  sj^stem,  to  aid  the  local  in  effecting  the  cure^ 
and  to  remove,  when  practicable,  the  effects  left  after  a  cure  of  the 
local  disease.  A  cure  of  local  chronic  disease,  by  general  treatment 
alone,  is  hardly  to  be  expected,  although,  in  some  instances,  it  may 
be  indispensable  to  such  a  result.  When  general  treatment  is  used  as 
a  palliative  or  adjunct  in  local  diseases,  it  is  directed  to  the  relief  of 
general  symptoms  attendant  U]3on  them.  It  will  be  impossible  for 
me  to  notice  the  treatment  necessary  in  all  the  symptoms  which  attend 
and  add  to  the  distress  of  our  ]3atients  in  uterine  diseases,  but  there 
are  certain  prominent  and  troublesome  ones  on  which  I  cannot  with 
propriety  omit  to  dwell.  I  do  so  the  more  readily  from  the  embarrass- 
ment which  I  know,  from  experience,  fills  the  mind  of  the  inexperi- 
enced as  to  the  proper  value  to  place  upon  general  treatment  and  the 
.course  to  be  pursued. 

Many  of  the  patients  laboring  under  chronic  uterine  disease  come 
to  us  broken  down,  the  subject  of  a  multitude  of  symptoms  resulting 
from  inanition  and  depraved  functions.  These  prostrated  patients, 
it  will  be  found,  have  passed  through  the  primary  sympathetic  suffer- 
ing I  have  elsewhere  described,  and  are  in  the  midst  of  that  condition 
we  have  been  in  the  habit  of  calling  nervous  prostration,  in  which 
general  treatment  becomes  a  very  important,  if  not  an  essential,  means 
of  success.  This  general  treatment  consists  in  the  correction  of  the 
condition  of  the  organs  which  were  first  sympathetically  deranged, — 
the  stomach  and  its  associate  organs, — introducing  into  the  system 
nutritive  material  enough  to  relieve  the  ansemic  state  of  the  nervous 
centres,  and  conducting  the  patient  back  to  her  long-lost  habits  of 
activity.  I  have  elsewhere  expressed  the  opinion  that  the  primary 
morbid  condition  of  these  organs  is  functional  derangement,  and, 
perhaps,  always  deficiency  of  their  secretions.  One  of  the  first  and 
most  important  things  to  be  done  is  to  correct  this  derangement,  and 
the  two  medicines  that  have  occurred  to  me  to  be  the  most  efficient 
are  mercury  and  nitro-muriatic  acid.  Mercury  has  always,  and  very 
deservedly,  had  the  reputation  of  exciting  the  glands  connected  with 
the  alimentary  canal,  viz.,  the  salivary,  gastric,  duodenal, — liver  and 
pancreas, — and  those  of  the  large  intestine.     Administered  in  small 


398  GENERAL  TREATMENT   OF  UTERINE   DISEASE. 

doses,  this  excitement  does  not  transcend  the  limits  compatible  with 
health ;  but  given  in  larger  doses,  it  produces  inflammatory  excite- 
ment in  all  of  them.  We  can  very  properly  avail  ourselves  of  this 
quality  of  mercury  in  such  a  manner  as  to  increase  the  action  of  all 
these  glands,  and  thus  promote  the  appetite,  and  digestion  and  assimi- 
lation. It  is,  in  this  way,  an  efficient  tonic,  increasing  the  red  blood- 
corpuscles  and  establishing  a  plastic  habit  so  desirable  in  chronic 
diseases.  To  these  broken-down  joatients  I  am  in  the  habit  of  admin- 
istering it  in  the  form  of  blue  mass  or  the  bichloride ;  of  the  former, 
one-third  of  a  grain  four  times  a  day,  or  one  grain  at  bedtime.  When 
I  give  the  bichloride,  I  generally  dissolve  it  in  the  compound  tincture 
of  cinchona,  one-sixteenth  of  a  grain  of  the  mercury  in  a  tablespoonful 
of  the  tincture  three  times  a  day,  after  meals.  These  doses  are  too 
small  for  some  patients  and  too  large  for  others.  When  not  large 
enough,  they  are  not  attended  with  any  appreciable  results,  in  which 
case  a  slight  increase  will  be  necessary.  When  the  dose  is  too  large 
it  generally  causes  diarrhoea.  When  it  produces  this  last  effect,  it 
should  be  withdrawn  and  the  acid  substituted,  which  should  be  given 
in  very  small  doses. 

Dr.  L.  F.  Warner,  of  Boston,  wrote  an  article  in  advocacy  of  the  use 
of  mercury  in  the  treatment  of  uterine  disease  for  the  obstetrical  sec- 
tion of  the  American  Medical  Association.  It  was  published  in  the 
Transactions  of  1878.  Dr.  Warner  brings  forward  cases  to  show  the 
efficacy  of  this  drug,  and  the  article  will  repay  perusal. 

It  should  be  remembered,  however,  that  medicines  are  but  prompt- 
ers to  nutrition,  and  that  to  reinstate  the  lost  vigor  the  patient  must 
be  fed.  Her  anorexia  should  be  no  excuse  for  starvation  ;  food  should 
be  taken  in  sufficient  quantities  to  nourish  her,  with  as  much  persist- 
ence and  regularity  as  she  takes  her  medicine.  If  we  wait  for  an 
appetite,  starvation  will  go  on ;  and  if  we  wait  until  digestion  is  com- 
fortable, we  may  often  wait  until  inanition  establishes  tuberculosis, 
leucocythsemia  or  some  other  equally  fatal  disease. 

We  ought  to  prescribe  and  particularize  what,  in  our  judgment,  is 
necessary,  and  insist  upon  its  being  taken.  About  the  only  reason  for 
withholding  any  article  of  diet  indicated  is  the  rejection  of  it.  Diges- 
tion is  likely  to  be  attended  with  discomfort  of  some  kind,  such  as 
fulness,  cardialgia,  pyrosis,  etc. ;  but  as  the  blood  becomes  better,  by 
virtue  of  its  tonic  influence  upon  the  organs,  the  secretions  in  the 
stomach  will  improve,  its  muscular  coats  become  stronger,  bile  and 
pancreatic  secretions  become  normal  in  quantity  and  quality,  and  the 
digestion  will  be  complete,  easy  and  comfortable,  and  the  patient 
will  regain  her  strength. 

The  articles  of  diet  which  can  be  tolerated  will  not  always  be  the 
same.  When  I  say  tolerated  I  do  not  mean  desired  and  digested  with 
comfort,  but  I  mean  such  as  will  not  be  rejected  from  the  stomach,  for 


NERVOUS   PEOSTEATION.  399 

if  they  are  not  vomited  up,  and  do  not  cause  diarrhoea,  they  will  be 
digested,  and  hence  be  the  source  of  nutrition. 

As  concentrated  food,  and  generally  the  most  nourishing,  are  the 
different  kinds  of  animal  food ;  beefsteak,  roast  beef,  mutton  chops, 
roast  or  boiled  mutton,  milk  and  eggs,  butter,  etc.,  constitute  a  good 
assortment  from  which  to  choose  and  prescribe. 

In  prescribing  meat  in  any  form  we  will  generally  be  met  with  the 
objection :  "I  do  not  eat  meat ;  I  do  not  care  for  meat ;  I  have  no 
appetite  for  it."  I  sometimes  think,  as  medical  men,  we  ought  to 
reject  the  word  appetite  from  our  vocabulary.  These  patients  usually 
have  no  appetite,  and  for  that  very  reason  are  starved.  If  we  do  not 
prescribe  the  very  articles  we  want  them  to  take,  the  exact  quantity 
and  the  time  for  taking  them,  they  will  generally  disregard  our  direc- 
tions. We  may  tell  them  to  take  two  ounces  of  beefsteak  or  mutton 
chop  for  breakfast,  the  same  quantity  for  suj^per,  four  ounces  for  din- 
ner, with  bread  and  butter,  vegetables,  and  every  such  other  thing  as 
they  wish,  but  always  the  meat.  Then  if  we  prescribe  one  pint  of 
milk  after  each  meal,  and  one  at  bedtime,  the  patient  will  have  a  good 
strong  diet,  and  it  will  soon  be  apparent  in  her  improved  condition. 
The  nurse  should  be  responsible  for  the  taking  of  this  prescription,  as 
she  is  for  the  administration  of  medicines. 

Some  patients  cannot  chew  their  meat,  but  can  swallow  and  digest 
it  if  it  is  minced  finely.  It  will  digest  in  this  form  usually  very  per- 
fectly. 

General  Symptoms  requiring  Special  Attention. 

The  symptoms,  the  treatment  of  which  I  propose  to  speak  of  in 
detail,  are :  1st.  General  nervous  prostration ;  2d.  Nervous  excitability, 
exaltation  of  nervous  excitement;  3d.  Ansemia ;  4th.  General  plethora ; 
5th.  Local  plethora ;  6th.  Constipation ;  7th.  Indigestion.  These  are 
generally  more  or  less  complicated  with  each  other,  and  sometimes 
several  of  them  coexist;  but,  ordinarily,  some  one  assumes  the  most 
prominence,  and  occasions  most  distress,  and  consequently  requires 
more  of  our  attention  than  the  others. 

Nervous  Prostration. 

There  is  often  great  nervous  prostration,  and  a  sense  of  weakness, 
when,  so  far  as  we  can  judge,  hsematosis  and  nutrition  are  usually 
well  performed.  The  cause  of  this  depression  must  be  sought  out 
in  each  case,  as  there  is  no  uniformity  in  the  functional  deviations. 
Very  frequently  there  is  a  deficiency  of  menstrual  discharge,  the 
scantiness  being  very  obvious ;  at  other  times  it  is  too  copious.  We 
should  inquire  into  the  functions  of  all  the  important  organs,  and 
correct  them,  when  disordered,  as  nearly  as  possible,  by  changing  the 
habits  and  circumstances  of  the  patient,  and  afterward,  or  in  connec- 


400  GENERAL   TREATMENT   OF   UTERINE   DISEASE. 

tion,  address  remedies  to  the  organs  themselves.  The  stomach,  liver, 
bowels,  skin,  kidneys,  and  uterus  should  furnish  their  discharges  in 
the  most  natural  manner,  and  if  they  are  not  doing  so,  should  be 
corrected  by  the  most  gentle  means.  If  several  of  these  organs  are 
in  a  state  of  functional  deviation  from  health,  we  should  not  expect 
to  correct  them  all  at  one  time,  but  alternate  our  attention  between 
them ;  first,  with  our  remedies  influencing  one,  and  then  another.  I 
insist  here,  with  reference  to  the  plan  to  be  pursued,  that  we  should 
not  address  all  these  organs,  or  even  a  large  part  of  them,  with  me- 
dicinal agents  at  one  time.  There  is  no  question,  I  think,  that  com- 
plicated formulae  often  nullify  themselves  by  containing  ingredients 
intended  for  the  liver,  kidneys,  and  skin,  which  ought  all  to  act  about 
the  same  time.  We  should  act  upon  each  of  these  alternately,  in 
quick  succession,  if  we  think  best;  but  let  each  organ  feel  the  full 
impression  of  its  remedy  before  the  blood  and  nervous  energies  are 
directed  to  another.  In  addition  to  this  indirect  way  of  increasing 
the  tone  of  the  nervous  system,  it  is  natural  for  us  to  look  about  for 
something  that  will  act  more  directly.  Our  patient  becomes  so  de- 
pressed, and  suffers  so  much  from  terrible  feelings  of  prostration,  that 
her  condition  appeals  to  our  sympathies  for  a  more  direct  and  imme- 
diate relief.  If  left  to  themselves,  or  the  advice  of  injudicious  friends, 
they  almost  always  resort  to  stimulants,  as  whiskey,  ether,  chloro- 
form, ammonia,  etc.  In  some  cases  only  are  these  temporary  reme- 
dies advisable,  and  when  used,  they  nearly  always  leave  the  patient 
in  a  worse  condition  than  before  they  were  taken.  They  are  allow- 
able only  as  necessary  evils,  and  should  be  avoided  when  possible. 
These  patients  are  usually  depressed  mentally,  also,  and  much  good 
may  be  done  by  operating  upon  their  minds.  A  physician  who  enters 
the  room  with  a  cheerful  countenance,  and  a  pleasant  and  gentle 
bearing  toward  the  patient,  and  who  engages  her  in  conversation, 
first  about  her  case,  and  afterward  about  some  favorite  theme,  will 
do  more  toward  temporarily  relieving  the  great  nervous  and  mental 
depression  than  all  the  ether  and  ammonia  the  stomach  can  be  made 
to  bear.  Earnest  and  kind  assurances  that  her  symptoms,  though 
causing  her  a  great  deal  of  suffering,  are  not  of  a  serious  nature,  and 
will  soon  subside,  act  generally  as  a  good  cordial  to  the  spirit  and 
nerves.  In  paroxysms  of  excessive  nervous  prostration,  despondency, 
etc.,  I  have  seen  the  tonic  influence  of  very  cold  air  do  a  great  deal 
toward  relieving  them.  These  paroxysms  generally  occur  in  close 
and  overheated  rooms,  two  conditions  which  should  be  removed.  If 
it  is  cold  weather,  we  should  cover  the  patient  to  protect  her,  and  let 
the  frosty  air — the  colder  the  better — into  the  room,  by  opening  all 
the  windows  and  doors,  and  keep  the  room  cleared  of  visitors.  It 
will  astonish  anybody  who  has  not  observed  the  effect  of  a  tem- 
perature near  to  zero  on  those  swooning  hypochondriacs.     A  change 


NERVOUS    EXCITABILITY.  401 

almost  immediately  occurs  for  the  better.  If  the  air  is  not  cold,  it 
will  still  do  much  good  to  give  it  perfectly  fresh  to  the  patients  in 
abundance.  When  able,  they  may  be  taken  outdoors.  This  treat- 
ment introduces  the  natural  stimulants,  oxygen  and  cold,  into  the 
lungs,  and  brings  them  in  contact  with  the  nerves,  and  is  more  en- 
livening than  medicine.  How  long  the  room  should  be  kept  open 
and  cold  will  depend  upon  the  effect,  but  we  should  always,  if  pos- 
sible, make  these  patients  sleep  in  open,  cold  rooms.  This  is  a  very 
important  item,  which  it  will  often  require  ingenuity  as  well  as 
authority  to  enforce.  These  patients  should  live  outdoors  as  nearly 
as  possible,  and  be  as  much  as  they  can  on  their  feet. 

Food,  etc. 

Their  food  should  have  reference  to  the  condition  of  the  abdom- 
inal functions  entirely,  and  be  regulated  by  them.  There  is  gener- 
ally great  intestinal  torpor,  which  should  be  removed  if  possible.* 
Good,  cheerful  company,  travel, — if  the  patient  will  not  employ  her 
body  and  mind  in  domestic  pursuits, — temperate  and  reasonable  di- 
versions, and,  above  all,  time  and  patience,  are  requisite  remedies. 
The  affection  is  obstinate  and  chronic,  and  with  the  most  judicious 
management  will  require  time,  if  it  does  not  vanish  as  the  local  treat- 
ment advances. 

Nervous  Excitability. 

Connected  with  it  often  in  some  manner  is  great  nervousness,  exci- 
tability, irritability,  or  exaltation  of  all  the  nervous  phenomena.  This 
nervous  irritability  shows  itself  in  great  mental  excitability,  want  of 
sleep,  unreasonable  agitation,  restlessness,  dissatisfaction  ;  in  short,  in 
almost  every  phase  of  mental,  muscular,  or  nervous  excitement. 
There  is  also  excitability  of  the  different  organs,  with  or  without 
general  nervousness,  palpitation  of  the  heart,  nervous  headache,  local 
muscular  contraction,  etc.  Successful  management  of  these  nervous 
and  excitable  patients  requires  a  careful  scrutiny  into  their  general 
condition ;  the  ehylopoetic  functions  should  be  regulated  in  the  most 
careful  manner,  the  skin  and  kidneys  should  be  attended  to  with  great 
watchfulness.  All  that  I  have  said  as  to  general  management  in  cases 
of  nervous  depression  will  apply  to  this  kind  of  cases.  As  complete 
a  revolution  of  the  circumstances  of  the  patient  should  be  made  as  is 
practicable.  From  a  life  of  ease,  luxury,  and  absence  of  care,  she 
should  be,  if  possible,  placed  in  circumstances  requiring  care,  with 
muscular  outdoor  exercise  to  the  greatest  extent  she  is  capable  of.  If 
we  cannot  place  our  patients  in  situations  which  their  cases  require, 
we  can  send  them  on  journeys  that  will  demand  exertion,  calculation, 

*  See  remarks  on  treatment  of  Constipation. 
26 


402  GEXERAL    TREATMENT   OF    UTERINE    DISEASE. 

care,  and  the  deprivation  of  their  usual  domestic  luxuries.  The  re- 
mark is  frequently  made  that  we  must  temper  our  remedies  to  the 
delicacy  of  the  patients ;  and  I  am  afraid  that  this  injunction  is  mis- 
construed into  the  necessit}^  of  too  great  tenderness  of  treatment.  The 
better  rule  is  to  make  use  of  such  means  as  will  raise  the  patient  from 
her  state  of  delicacy  to  robustness.  It  is  the  delicacy  of  her  constitu- 
tion that  causes  her  to  suffer  so  much.  This  can  be  strengthened  onl}'- 
by  proper  physical,  moral,  and  mental  training.  The  moral  and 
mental  condition  of  our  patients  when  so  very  excitable  should  be 
attended  to.  Improper  reading  and  society  should  be  avoided,  and 
social  and  literary  habits  should  be  reduced  to  great  plainness  and 
simplicity.  Above  all  things,  books  and  society  should  not  interfere 
with  regular  rest,  exercise,  and  outdoor  exposure.  As  I  have  said 
before,  this  last  should  be  as  great  in  amount  as  can  be  borne,  accom- 
panied with  active  muscular  exercise,  as  walking,  and  should  be  prac- 
ticed in  all  weathers,  sufficient  protection  being  secured  by  enough 
clothing  of  the  right  sort.  With  regard  to  the  use  of  medicine,  is  is  a 
fact,  that  it  is  an  exceedingly  difficult  thing  to  find  any  remedy  that 
does  not  produce  exaggerated  and  in  most  cases  disagreeable  and  even 
injurious  effects.  So  much  excitability  of  the  nervous  system  nearly 
always  modifies  the  effects  of  remedies,  and  we  can  seldom  predict 
the  operation  of  any  of  them,  nor  can  we  determine  the  value  of  any 
until  they  have  been  tried.  When  tonics  can  be  borne,  they  often 
very  much  relieve  and  sometimes  entirely  cure  this  great  nervous  ex- 
citability. Of  the  mineral  tonics,  probably  bismuth,  arsenic,  and  zinc, 
agree  best.  Iron  is  frequently  not  tolerated  in  any  shape  by  these 
very  nervous  patients.  Quinine,  nux  vomica,  cherry,  and  chamomile 
are  the  best  vegetable  tonics,  but  we  must  not  be  surprised  if  none  of 
them  are  borne.  Alcoholic  stimulants,  in  general^  agree  with  them, 
and  are  the  best  cordials  for  temporary  nervous  excitement,  but  should 
be  conscientiously  avoided  when  possible,  as  not  a  few,  I  am  sorry  to 
say,  of  most  estimable  and  intelligent  women  have  useJ  them  too 
much,  and  engendered  an  appetite  that  could  not  be  denied.  Opium, 
and,  in  fact,  the  narcotics  generally,  fail  to  have  any  good  effect,  but 
on  the  contrary  disagree  with  the  patient.  This,  however,  is  not 
always  the  case  with  opium,  as  it  acts  like  a  charm  with  some.  In 
all  it  should  be  studiously  avoided  as  deleterious  in  the  long  run, 
and  there  is  danger  of  creating  an  appetite  for  it.  We  may  the  more 
readily  be  persuaded  to  omit  the  use  of  all  these  medicines,  as  their 
effects  are  temporary,  while  remedies  hygienic  and  regiminal  are  per- 
manent in  their  effects.  The  management  of  those  cases  of  localized 
nervousness  or  unnatural  excitability  in  particular  organs,  as  palpita- 
tions of  the  heart,  nervous  headache,  etc.,  is  about  the  same  as  above, 
except  that  more  attention  to  the  stomach,  from  which  they  usually 
arise,  may  be  necessary. 


ANEMIA.  403 

Some  forms  of  nervous  excitement  are  very  much  benefited  by  the 
bromide  of  potassium.  Severe  nervous  headache,  watchfuhiess  and 
neuralgic  pains  are  often  greatly  relieved  by  this  remedy.  It  should 
be  given  in  full  doses.  For  headache,  from  thirty  to  sixty  grains 
every  hour  until  relief  is  obtained.  For  wakefulness,  the  same  quan- 
tity an  hour  before  and  at  bedtime  will  sometimes  procure  a  good 
night's  rest.  When  given  in  full  doses  it  should  be  dissolved  in  a 
large  quantity  of  water,  to  prevent  it  from  irritating  the  mucous 
membrane  of  the  alimentary  canal.  I  have  sometimes  succeeded  in 
averting  the  return  of  the  syncopal  convulsions  described  under  the 
head  of  general  symptoms.  One  patient  now  under  my  care  had 
been  the  subject  of  them  for  twelve  months,  having  them  several 
times  a  month.  They  had  become  so  frequent  and  violent  as  to 
induce  the  fear  of  epilepsy,  and  had  been  treated  with  many  remedies 
without  material  benefit.  She  has  been  taking  the  bromide  of  potas- 
sium for  six  months  in  doses  of  thirty  grains  three  times  a  day,  and 
during  that  time  has  had  no  convulsions.  She  is  under  treatment  for 
endocervicitis.  It  remains  to  be  seen,  of  course,  whether  this  im- 
provement be  permanent,  nor  can  I  say  how  much  of  the  ameliora- 
tion may  depend  upon  the  treatment  directed  especially  to  the  uterus. 
It  is  certain,  however,  that  the  "  paroxysms,"  as  she  calls  them,  were 
improved  immediately  upon  the  commencement  of  the  bromide  treat- 
ment, and  before  I  could  reasonably  expect  benefit  from  the  rest  of  the 
remedies. 

We  undoubtedly  have  a  valuable  means  of  relief  from  the  pains 
attendant  upon  the  condition  of  many  of  these  patients  in  the  hy- 
drate of  chloral,  while  it  is  often  as  prompt  and  positive  in  the  relief 
it  affords  in  sleeplessness  and  pain.  So  far  as  I  am  aware,  it  is  not 
followed  by  the  very  disagreeable  effects  that  result  from  the  adminis- 
tration of  opium  and  its  preparations.  It,  too,  should  be  dissolved 
in  an  abundance  of  water,  to  prevent  it  from  producing  local  irrita- 
tion upon  the  mucous  membrane  of  the  stomach,  as  it  often  otherwise 
causes  vomiting  or  decided  nausea. 

Ansemia. 

Anaemia,  with  its  disagreeable  concomitants,  sometimes  also  calls 
for  separate  treatment.  It  would  be  an  unnecessary  waste  of  time  and 
space  to  enter  minutely  into  the  general  treatment  necessary,  where 
ansemia  is  the  prominent  and  troublesome  symptom.  This  condition 
calls  for  the  same  treatment  found  useful  under  other  circumstances, 
and,  while  it  may  not  be  entirely  amenable  to  it,  it  will  be  very  much 
benefited  by  the  remedies  indicated  by  the  state  of  the  blood.  Iron, 
cod-liver  oil,  quinine,  bitter  infusions,  and  nutritious  diet,  with  out- 
door exercise  to  the  extent  the  patient  can  bear,  are  the  efficient 
remedies. 


404  GENERAL   TREATMENT    OF    UTERINE    DISEASE. 

Plethora. 

But  ^ve  soinetimes  find  general  plethora  instead  of  anaemia,  a  state 
in  which  there  is  actually  an  unusual  amount  and  too  rich  a  com- 
position of  the  blood.  I  need  not  dwell  upon  this  general  state  of 
the  system,  as  the  treatment  is  simple  and  familiar.  The  great  fear 
is  that,  on  account  of  the  painfulness  about  the  hips  and  legs,  the 
patient  may  be  too  much  inclined  to  an  inactive  life.  On  no  account 
should  this  class  of  patients  be  allowed  their  ease;  they  must  be 
urged  to  use  up  their  surplus  blood  in  active  exercise,  and  the  kind 
of  exercise,  next  to  the  cares  and  labor  of  a  household,  best  adapted 
to  them,  is  walking.  Every  muscle  in  their  body  must  be  brought 
into  action ;  every  secretion  must  be  kept  free,  and  the  mind  ought 
to  be  taxed  to  continuous  effort  during  the  day  by  some  useful  occu- 
pation, while  the  strictest  temperance,  with  reference  to  ingesta, 
should  be  their  rule  of  living.  Obesity,  and  the  troublesome  and 
dangerous  effects  of  plethora,  connected  or  unconnected  with  general 
plethora,  will  be  thus  avoided. 

Local  Caagestions. 

We  sometimes  meet  with  instances  of  violent,  dangerous,  and  even 
fatal  determinations  of  blood  to  particular  organs,  as  the  consequence 
of  the  general  ill-health  which  accompanies  uterine  disease,  such  as 
stupor,  stertorous  breathing,  etc.,  indicating  an  oppressed  condition  of 
the  brain,  great  dyspnoea,  and  sense  of  suffocation,  showing  congestion 
of  the  lungs.  The  treatment  of  these  congestions  does  not  differ  from 
what  would  be  appropriate  under  other  circumstances  of  their  occur- 
rence, and  consists  in  revellents,  alteratives,  etc.  The  most  frequent, 
and  perhaps  obstinate,  of  the  local  congestions  are  such  as  occur  in  the 
chylopoetic  viscera,  manifested  by  excessive  secretion  and  discharges 
from  the  stomach  and  bowels.  It  is  not  uncommon  for  these  patients 
to  have  suddenly  recurring  attacks  of  vomiting,  cramps  in  the  stomach 
and  bowels,  diarrhoea,  and  consequent  great  distress.  Aside  from  the 
.local  treatment,  we  shall  be  called  upon  to  exert  our  skill  against  the 
exhausting  and  depressing  influences  of  these  attacks.  It  will  almost 
always  be  found  that  such  attacks  are  preceded  by  constipation,  with 
scanty  secretions,  furred  tongue,  and  other  e"vddence  of  unhealthy 
secretions.  By  carefully  correcting  this  condition  we  may  avert  these 
painful  and  exhausting  occurrences.  The  plan  recommended  and  so 
much  prescribed  by  Abernethy  will  often  palliate  very  much,  \az., 
six  or  eight  grains  of  blue  mass,  at  night,  worked  off  by  some  saline 
cathartic  in  the  morning  of  every  fourth  or  fifth  day.  If  there  is 
more  permanent  diarrhoea,  great  care  should  be  exercised  in  the  choice 
of  diet;  the  use  of  warm  baths  should  be  recommended,  very  warm 
clothing,  and  not  much  medicine,  as  the  cure  will  depend  upon  the 


CONSTIPATION.  405 

appropriate  treatment  of  the  local  disease,  instead  of  the  treatment  of 
the  general  symptoms.  All  these  symj)toms,  except  the  diarrhoea,  are 
apt  to  be  moderate,  and  can  be  borne  until  the  diseased  uterus  is  cured ; 
but  there  are  two  symptoms  so  very  annoying,  and  which  require  so 
much  patience  in  the  treatment,  and  exercise  so  much  unfavorable 
influence  upon  the  uterine  disease,  that  I  hope  I  shall  be  pardoned  by 
the  reader  for  dwelling  upon  them  more  at  length. 

Constipation. 

I  allude  to  constipation  and  indigestion,  particularly  the  former. 
I  have  already  spoken  of  the  deleterious  influence  of  constipation, 
and  I  think  I  am  justified  in  saying  that,  if  disregarded,  it  retards 
the  cure  of  chronic  diseases  of  the  unimpregnated  uterus  more  than 
any  other  sympathetic  affection.  And  I  wish  to  warn  the  practitioner 
to  be  very  particular  in  attending  to  this  symptom.  There  is  proba- 
bly more  tendency  to  costiveness  in  females  than  in  males,  chiefly 
owing  to  difference  in  habits.  Sedentary  life,  confinement  to  close, 
badly  ventilated  rooms  are  among  the  circumstances  that  bring  on 
this  condition.  Irregularity  of  meals,  late  hours,  deficient  sleep,  con- 
centrated diet,  imperfect  mastication  of  food,  all  should  be  corrected, 
as  any  one  of  them  alone  will  do  harm,  and  all  or  any  of  these  com- 
bined— and  this  is  frequently  the  case — are  very  deleterious  to  the 
'functions  of  the  alimentary  canal.  But  an  inexcusable  and  very  com- 
mon custom  of  most  females  is  making  the  act  of  defecation  a  disa- 
greeable and  procrastinated  necessity,  instead  of  a  pleasant  and  punc- 
tual duty.  The  most  trivial  excuse — the  presence  of  friends ;  a  little 
cold,  hot,  or  wet  weather;  being  among  strangers;  or  a  slightly  in- 
convenient distance  from  a  j)roper  place — will  frequently  be  sufficient 
to  limit  defecation  to  once  a  week;  then  the  act  is  performed  in  a 
hurried  manner.  It  is  amazing  to  know  to  what  lengths  this  negli- 
gence is  often  carried.  I  have  known  two  weeks  to  have  transpired, 
frequently,  according  to  the  history  of  patients,  without  any  attempt 
to  relieve  the  bowels.  Now  this  should  be  corrected  by  persistent 
method.  The  habit  of  eating  from  hunger  at  certain  hours  depends 
upon  hfelong  practice,  and,  when  once  established,  cannot  be  changed 
without  violence  to  many  functions,  causing  urgent  and  repeated  de- 
mands upon  the  system  for  a  resumption  of  it.  Regular  bowels  come 
from  an  equally  long-continued  habit  of  going  to  the  close-stool  at 
particular  hours  of  the  day.  Years  of  negligence  destroy  the  habitual 
regularity  with  which  the  bowels  move;  hence  we  should  not  be  dis- 
couraged if  the  habit  be  not  re-established  without  long  perseverance. 
A  new  habit  cannot  be  formed,  nor  an  old  one  altered,  without  long 
and  persevering  effort  in  the  right  direction.  We  should,  therefore, 
encourage  a  patient  that  is  in  earnest  in  her  search  after  health,  to 


406  GENERAL    TREATMENT   OF    UTERINE   DISEASE. 

persevere  for  months,  years,  and  indeed  her  whole  life  if  necessary, 
in  going  to  her  water-closet  without  fail,  once  every  da}^,  at  a  certain 
hour,  as  regularly  as  the  clock  points  to  it.  This  is  indispensable  to 
a  correction  of  the  bad  habit  of  constipation.  A  very  effective  part 
of  this  regular  endeavor  is  to  cause  the  mind  to  dwell  upon  the  neces- 
sity for  an  evacuation,  and  the  process  itself,  for  at  least  half  an  hour 
before  retiring  to  the  proper  place.  It  is  not  a  difficult  matter,  with 
many  persons,  to  create  a  desire  in  this  way.  Let  no  consideration 
of  convenience  enter  into  this  punctual  effort  at  stool.  Arrived  at 
the  proper  place,  the  position  should  be  an  easy  one;  no  inconvenient 
strain  upon  any  muscle  should  be  allowed,  and  the  patient  should  be 
possessed  with  an  entire  sense  of  leisure  to  perform  the  act  completely. 
The  value  of  all  these  considerations,  where  faithfully  followed,  is 
incalculable,  and  very  few  cases  can  long  resist  them.  Without  them, 
medicine  will  only  temporarily  relieve,  instead  of  permanently  curing 
obstinate  cases.  I  should  caution  against  severe  effort,  or  straining, 
as  it  is  called;  let  time,  patience,  and  gentle  effort  be  the  plan. 
Another  matter  of  great  importance,  when  an  effort  is  made  to  have 
an  evacuation,  is  to  have  the  abdomen  distended  by  ingesta.  The 
patient  should  be  instructed  to  eat  plentifully  of  vegetable  diet,  such 
as  by  its  bulk  is  calculated  to  produce  fulness.  If  the  patient  go  to 
the  water-closet  with  a  sense  of  fulness  in  the  abdomen,  success  will 
be  much  more  likely.  Should  the  regular  time  for  making  an  effort 
be  soon  after  breakfast,  which  is  undoubtedly  the  best  time,  and  the 
meal  has  not  been  sufficient  to  produce  a  sense  of  moderate  distension, 
a  full  glass  of  water  will  complete  that  condition.  For  the  purpose 
of  giving  fulness  and  a  sense  of  distension,  various  kinds  of  ripe  fruit 
may  be  resorted  to  with  advantage.  In  prescribing  fruit  for  consti- 
pation, we  should  bear  in  mind  that  there  are  three  indications  ful- 
filled by  it,  some  kinds  fulfilling  all,  while  others  fulfil  only  a  part 
of  them.  They  are,  first  and  best,  distension;  secondly,  increase  of 
secretion,  on  account  of  the  acids;  and,  thirdly,  increasing  peristaltic 
action  of  the  bowels  by  indigestible  fibres,  seeds,  or  rind.  Ripe  and 
mellow  apples,  without  being  divested  of  the  rind,  may  be  eaten  in 
sufficient  quantities  to  produce  a  sense  of  fulness,  and  this  should 
always  be  at  the  conclusion  of  a  meal, — breakfast,  for  instance;  the 
acids  will  increase  the  intestinal  secretion,  and  the  rind  quicken  the 
peristaltic  motion  of  the  bowels  by  acting  directly  upon  the  mucous 
membrane,  and  through  it  on  the  muscular  structure.  Very  acid 
fruits,  as  the  lemon  and  orange,  only  produce  their  effect  on  account 
of  the  acids  they  contain.  They  are  excellent  as  a  part  of  the  ingesta 
of  patients  whose  stools  are  dry  and  hard  and  lumpy.  Fruits  con- 
taining an  abundance  of  seeds,  as  figs,  or  of  rind,  as  tamarind,  etc., 
increase  the  peristaltic  action  without  causing  much  secretion.  By 
inquiring  into  the  character  of  the  stools,  we  shall  have  a  good  guide 


CONSTIPATIOX.  407 

as  to  the  kind  or  mixture  of  fruits  to  be  selected.  There  are  kinds 
of  diet,  breads  particularly,  that  act  like  these  last  fruits,  and  may  be 
used  in  conjunction  with  or  independent  of  them.  Breads  in  which 
the  bran,  or  hull  of  the  grain,  is  contained  in  considerable  quantities 
are  of  this  character.  The  Graham  bread,  as  it  is  usually  called, 
ordinary  coarse,  brown,  corn  bread,  or  wheat  bread,  are  those  mostly 
resorted  to.  When  this  kind  of  bread  is  used  for  constipation,  it 
should  be  eaten  at  breakfast,  dinner,  and  supper,  in  such  quantities 
as  the  experience  of  the  patient  finds  necessary.  I  have  advised 
patients  who  could  not  use  the  coarse  breads  to  make  what  may  be 
called  bran  crackers.  A  tablespoonful  of  flour,  one  pint  of  wheat 
bran;  two  tablespoonfuls  of  white  sugar,  and  water  enough  to  make 
them  all  into  a  pasty  mixture,  are  the  ingredients.  This  mixture  is 
made  into  cakes,  small  or  large,  as  may  be  wished,  and  baked  in  an 
oven  until  hard.  When  soaked  in  tea,  coffee,  or  milk,  they  are  not 
unpleasant.  I  have  known  patients  benefited  by  swallowing  certain 
seeds,  with  the  rind,  whole.  A  tablespoonful  of  wheat  grains,  oats, 
barley,  white  mustard  seed,  etc.,  can  all  be  used  for  this  purpose,  and 
are  not  more  disagreeable  than  medicines.  Another  kind  of  diet, 
which  may  be  used  to  produce  the  kind  of  effect  here  aimed  at,  con- 
sists of  the  various  small  vegetables,  as  celery,  radishes,  pepper-grass, 
lettuce,  asparagus,  cabbage,  etc.  These  may  all  be  taken  in  quantities 
to  cause  distension. 

In  speaking  of  fruits,  I  ought  to  mention  the  berries  as  excellent, 
cheap,  and  easily  procured,  to  accomplish  all  the  objects  attained  by 
other  fruits. 

Everything  should  be  done  by  habitual  effort,  exercise,  diet,  drink, 
etc.,  before  resorting  to  the  use  of  medicines;  because,  as  is  well 
known  to  the  patients  generally,  as  well  as  to  the  practitioner,  the 
more  medicines  taken  the  more  will  be  necessary.  They  lose  their 
influence,  and  the  dose  must  be  increased  in  order  to  produce  a  full 
effect.  Notwithstanding  this  evil,  we  are  often  reduced  to  the  necessity 
of  using  laxatives  to  overcome  constipation.  To  a  just  and  intelligent 
application  of  medicines  in  the  treatment  of  constipation,  it  is  indis- 
pensably necessary  to  make  ourselves  acquainted  with  the  condition 
of  the  alimentary  canal,  with  reference  to  its  secretions  and  muscular 
powers.  It  will  be  found  that  there  are  sometimes  great  deficiency  of 
secretion,  and  torpor  or  want  of  vitality  of  the  muscular  structure,  or 
weakness  of  this  tissue.  The  want  of  secretion  may  be  in  the  upper 
portion,  in  which  case  the  bilious  color  is  wanting  in  the  stools,  or  the 
small  intestines  may  give  out  less  watery  material,  and  then  the  stools 
are  less  fluid,  or  even  dry.  The  secretions  may  also  be  deficient  in  the 
lower  portion,  or  colon  ;  in  which  case  the  fseces  will  be  scybalous,  dry, 
and  lumpy.  The  muscular  torpor,  from  want  of  irritability,  is  more 
frequent  in  the  colon  or  rectum  than  in  the  small  intestines.     When 


408  GENERAL   TREATMENT    OF    UTERINE    DISEASE. 

in  the  colon,  there  is  increase  in  size  of  the  lower  abdomen,  sense  of 
fulness  and  hardness,  and  the  fseces  are  expelled  vdth  great  difficulty. 
If  there  is  sufficient  activity  of  the  colon,  but  the  rectum  is  torpid, 
large  accumulations  occur  there,  the  pelvic  distress  is  increased,  and 
nervousness,  general  and  local,  is  exceedingly  annoying.  Sometimes 
all  these  conditions  are  combined  to  render  the  case  one  of  the  most 
troublesome  and  difficult  to  manage.  Mechanical  obstruction  by 
stricture  of  the  rectum,  formed  by  pressure  of  the  uterus,  may  give 
rise  to  chronic  constipation,  which  may  become  permanent  and  almost 
incurable ;  or  the  uterus,  by  lying  on  the  bowel,  and  pressing  it  against 
the  sacrum,  often  gives  rise  to  costiveness,  that  can  be  removed  only 
by  correcting  the  position  of  that  organ.  It  is  not  sufficient  to  know 
that  the  patient  does  not  have  regular  oiDerations  from  the  bowels, 
but  Ave  must  know  why  she  is  thus  constipated  :  whether  on  account 
of  want  of  secretion,  and,  if  so,  of  what  secretion ;  whether  it  is  at- 
tributable to  general  debility,  combined  with  muscular  weakness  of 
the  intestines,  or  to  lack  of  irritability  of  the  intestinal  tube  and  con- 
sequent torpor ;  and  if  so,  whether  this  lack  of  irritability  exists  in 
the  whole  length  of  the  canal,  in  the  colon,  or  the  rectum.  We  must 
also  know  whether  there  is  obstruction  from  stricture  in  the  rectum, 
piles,  thickening  in  the  mucous  membrane,  rigidity  of  the  sphincter, 
or  from  the  uterus  bearing  heavily  upon  it.  To  give  a  laxative  merely 
because  it  ordinarily  produces  a  fecal  discharge,  is  always  unphilo- 
sophical,  and  sometimes  exceedingly  injurious  in  its  effects.  I  think 
it  is  inattention  to  the  exact  state  of  the  alimentary  canal  that  makes 
constipation  so  often  incurable.  For  constipation,  attended  with  very 
dry,  hard  stools,  showing  a  deficiency  in  all  the  secretions  from  the 
bowels,  in  addition  to  the  course  of  diet,  including  acid  fraits,  etc.,  our 
object  should  be  to  administer  such  drugs  as  will  most  effectually  stimu- 
late to  secretion.  The  various  saline  medicines  are  indicated.  Sul- 
phate of  magnesia  is  a  most  excellent  one ;  and  a  good  way  of  admin- 
istering it  is  in  combination  with  sulphuric  acid.  From  one  to  two 
drachms,  or  even  half  an  ounce,  given  in  combination  with  acid 
enough  to  taste  somewhat  sharply,  will  promote  secretion  along  the 
whole  of  the  small  intestines,  cause  a  large  effusion  of  water,  which 
will  dissolve  the  fasces  and  render  their  evacuation  easy  and  sure.  In 
the  morning,  some  time  before  eating,  is  the  best  time  to  take  it.  When 
there  is  reason  to  believe  that  the  portal  circulation  is  slow,  and  the 
liver  furnishing  less  than  its  usual  amount  of  secretion,  some  form  of 
mercurial  should  be  used  with  the  salts.  If  the  case  is  chronic  and 
the  constipation  obstinate,  we  may  give  from  six  to  ten  grains  of  blue 
mass  in  pills,  at  bedtime,  every  fourth  or  fifth  night,  and  follow  it 
with  Ei^som  salts  in  the  morning.  A  continuance  of  this  alterative 
cathartic  from  four  to  six  weeks,  seldom  fails  to  cause  a  change  in  the 
alimentary  secretions.     Sometimes  it  is  better  to  give  these  cathartics 


CONSTIPATIO]!^.  409 

nearer,  and  sometimes  farther  apart.  We  must  judge  of  this  more  by 
the  susceptibility  to  the  constitutional  influence  of  mercury  than  any 
thing  else.  It  is  almost  always  the  case  that  this  very  scanty  state  of 
the  secretions  is  accompanied  with  an  impoverished  state  of  the  blood ; 
hence  iron  in  some  shape  will  be  beneficial  in  most  cases.  If  there  is 
much  debility,  a  long  course  of  tonics  will  be  indispensable.  It  may 
often  happen  that  this  scanty  condition  of  the  secretions  is  attended 
with  debility  of  the  muscular  fibre  of  the  intestinal  canal.  When 
this  is  the  case,  we  must  add  to  the  above  treatment  that  which  is  ap- 
plicable to  this  kind  of  intestinal  torpor,  which  I  shall  now  consider. 
Before  doing  so,  however,  I  will  remark  that  several  other  salts  will 
answer  as  well,  and  sometimes  even  better,  than  sulphate  of  magnesia. 
The  kinds  of  tonics  which  are  most  effectual  in  debility  of  the  muscular 
structure  of  the  intestinal  canal  are  such  as  give  general  strength,  and 
it  is  most  desirable  to  combine  them  with  special  tonics.  The  latter 
are  rhubarb  and  nux  vomica.  These  have  always  seemed  to  me  to 
have  a  special  tonic  influence  upon  the  intestinal  tube,  and,  when 
properly  given,  to  increase  the  susceptibilit}'  to  their  own  action.  The 
rhubarb,  although  an  alimentary  tonic,  induces  less  susceptibility  to 
its  own  influence  than  the  nux  vomica.  The  best  way  to  give  the 
rhubarb  is  either  in  the  root,  without  pulverization,  or  in  the  extract. 
When  given  alone  in  the  root,  the  patient  can  take  a  little,  twice  a  day, 
by  chewing,  and,  after  mixing  with  the  saliva,  swallowing  it.  A  little 
'experience  will  enable  the  patient  to  judge  of  the  right  quantity,  which 
she  can  repeat  as  often  as  it  is  required.  When  the  rhubarb  is  taken 
this  way,  she  may  also  take  a  solution  of  ferri  sulph.  and  strychnia,  in 
water,  one  grain  of  the  former  to  one-sixteenth  of  a  grain  of  the 
latter. 

I  have  often  succeeded  in  overcoming  this  constipation  or  debility 
by  giving  one  grain  of  quin.  sulph.  with  five  grains  of  powdered  nux 
vomica  after  each  meal.  Or  the  same  amount  of  nux  vomica,  with 
iron  by  hydrogen,  two  grains  each  time,  after  eating.  It  is  usual  to 
use  aloes  in  the  constipation  of  uterine  diseases ;  but  I  have  found 
very  few  cases  with  which  this  drug  did  not  disagree.  But  there  is 
a  torpor  of  the  intestines  where  general  tonics  cannot  be  borne; 
where,  in  fact,  there  does  not  seem  to  be  any  general  debility,  there 
is  only  a  want  of  susceptibility  to  the  stimuli  which  ordinarily  arouse 
them  to  action.  The  secretions  color  the  fseces  properly,  and  give 
them  sufficient  moisture ;  there  seems  to  be  no  fault  in  their  appear- 
ance, consistence,  odor,  or  other  character  whatever.  They  are  de- 
ficient only.  The  patient  may  be  plethoric  and  florid,  her  general 
muscular  strength  sufficient,  and  her  blood,  so  far  as  we  can  judge, 
good  in  composition.  Special  tonics  and  stimuli  are  indicated  in 
such  instances,  and  they  alone  should  be  used.  Such  measures  should 
be  adopted  as  will  arouse  the  muscular  action  of  the  intestines.     Nux 


410  GENERAL    TREATMENT    OF    UTERINE    DISEASE. 

vomica,  in  five-grain  doses,  with  the  rhubarb  extract  or  without  it, 
or  the  strychnia  in  solution,  in  doses  from  a  sixteenth  to  a  twentieth 
of  a  grain,  constitute  our  most  valuable  medicinal  remedies.  This 
is  the  kind  of  constipation  that  is  most  benefited  by  and  is  most 
amenable  to  a  persevering  regiminal  and  dietetic  course  of  manage- 
ment, such  as  I  have  endeavored  to  give. 

In  addition  to  the  rhubarb  and  nux  vomica  treatment,  we  may  get 
some  good  from  external  apj)liances,  and  manipulations  of  the  walls 
of  the  abdomen.  The  most  valuable,  when  gentl}'',  perseveringly, 
and  methodically  applied,  is  what  is  understood  b}'  the  term  knead- 
ing. The  colon  is  the  torpid  portion  in  most  cases  of  this  sort  of 
constipation.  The  jDrocess  of  kneading  consists  in  handling  it  so  as 
to  stimulate  its  fibres  directl3^  One  plan  is  to  grasp  it  with  the  hand, 
and  squeeze  it  from  one  end  to  the  other.  We  should  begin  at  the 
right  groin,  and  with  a  knowledge  of  the  position  and  direction  of  it, 
grasp  it  with  both  hands  at  this  point,  then  a  little  higher  up  on  the 
same  side,  and  then  a  little  higher,  until  we  reach  the  right  hypo- 
chondriac region.  We  should  then  follow  it  across  the  abdomen  to 
the  left  hypochondriac  region,  and  thence  down  to  the  left  iliac.  Or, 
we  may  double  our  hands  as  bakers  do  when  kneading  their  dough, 
and  standing  over  the  patient,  press  with  the  knuckles  of  both  hands, 
first  in  the  right  iliac  region,  and  imitating  the  process  of  kneading, 
pass  slowly  from  this  to  the  right  hypochondriac,  thence  across  the 
abdomen  and  down,  as  before  directed.  If  we  trust  this  process  to  a 
non-professional  attendant,  we  should  be  sure  to  show  him  how  to  do 
it,  as  it  is  important  that  it  should  be  done  right.  When  this  process 
of  kneading  or  squeezing  the  colon  is  first  instituted,  it  should  be 
practiced  with  the  utmost  gentleness,  but  the  force  and  rapidity  of 
motion  may  be  increased  until  great  freedom  ma}'  be  used.  It  should 
be,  resorted  to  a  short  time  before  retiring  to  the  water-closet,  sa}"  half 
an  hour.  Some  patients  find  an  efiicient  laxative  in  what  they  some- 
times call  a  water-compress,  applied  to  the  abdomen  overnight.  It  is 
made  b}^  doubling  a  naj^kin  several  times,  so  as  to  make  a  thick  com- 
press, large  enough  to  cover  the  entire  abdomen  anteriorly.  This  is 
saturated  with  water,  and,  after  being  placed  upon  the  abdomen, 
covered  with  a  roller  or  bandage  so  as  to  keep  it  in  j^lace.  It  is  thus 
allowed  to  remain  from  the  time  of  going  to  bed  until  the  time  to  rise 
in  the  morning.  I  think  this  water-compress  is  best  adapted  to  cases 
in  which  there  is  a  deficiency  of  secretion  in  the  intestinal  tube. 

A  bandage,  or,  what  is  better,  a  roller  applied  tightly  enough  to 
press  the  wall  strongly  upon  the  contents  of  the  abdomen,  frequently 
stimulates  them  to  proper  action,  both  as  it  respects  secretion  and 
peristalic  motion.  When  it  is  determined  to  use  the  roller  or  band- 
age for  its  stimulating  influence,  it  ought  to  be  applied  upon  rising 
in  the  morning,  or,  what  is  perhaps  better,  immediately  after  break- 


CONSTIPATION.  411 

fast.  This  bandage  should  not  be  worn  constantly,  nor  even  many 
hours  m  the  day.  From  the  time  of  rising  until  two  hours  after 
breakfast,  or  from  breakfast  for  three  hours  thereafter,  will  be  long 
enough.  The  constant  use  of  the  bandage  would  but  increase  the 
evil — lax  abdominal  muscles — for  which  it  is  advised.  Before  leav- 
ing this  part  of  the  subject,  I  desire  to  say,  with  reference  to  the  free 
use  of  nux  vomica  to  overcome  intestinal  torpor,  that  in  all  cases  we 
should  remember  its  effects  are  cumulative,  and  quite  a  difference  of 
susceptibility  to  its  influence  is  manifested  by  different  persons,  in 
consequence  of  which  the  patient  should  be  watched,  and  the  dose 
graduated  to  the  least  quantity  necessary  in  the  case.  Although  I 
have  given  nux  vomica  and  strychnia,  for  a  considerable  length  of 
time  to  a  great  variety  of  persons,  and  for  several  weeks  together,  I 
have  never  seen  anything  more  than  slight  inconvenience  from  it  in 
the  shape  of  nervous  startings.  Very  rarely  we  meet  persons  who 
cannot  take  it  at  all;  it  disagrees  with  them  as  soon  as  they  commence 
its  use. 

There  is  another  species  of  intestinal  torpor  of  a  very  obstinate 
character  and  very  distressing  to  the  patient ;  I  mean  a  lax,  torpid 
rectum  ;  so  torpid  as  to  allow  the  faeces  to  accumulate  in  large  quan- 
tities, and  cause  great  inconvenience  from  pressure.  To  such  an  ex- 
tent does  this  collection  sometimes  go  as  to  press  the  posterior  wall 
of  the  vagina  forward  and  protrude  it  between  the  labia.  The  first 
'indication  in  such  cases  is  to  dissolve  the  fecal  mass  and  discharge  it. 
Various  kinds  of  injections  are  useful  for  this  purpose,  warm  oil, 
warm  water,  etc. ;  but  one  which  I  have  seen  do  much  good  is  com- 
posed of  one  ounce  of  fresh  ox-gall  and  four  ounces  of  warm  water. 
This  composition  dissolves  the  fseces  very  readily,  and  the  fresh  bile 
stimulates  the  intestines  to  their  expulsion.  The  evacuation,  of  course, 
will  give  only  temporary  relief,  and  there  remains  the  most  important 
indication,  that  of  giving  tone  to  the  bowels,  with  a  view  of  prevent- 
ing the  accumulation  in  future.  This  is  difficult,  and  in  some  in- 
stances of  long  standing  quite  impossible.  Much  good  can  be  done 
in  nearly  all  cases,  however,  and  we  do  not  discharge  our  duty  if  we 
do  not  try  to  relieve  when  we  cannot  cure.  Cold  water  thrown  into 
the  rectum  once  or  twice  a  day,  in  small  quantities — eight  ounces — 
is  always  good,  without  some  special  reason  to  the  contrary.  There 
are  generally  two  indications  to  be  fulfilled  in  these  cases, — relaxation 
of  the  sphincters  and  restoration  of  the  tonicity  of  the  proper  rectal 
fibres. 

It  is  a  singular  fact,  which  I  think  I  have  observed,  that  the 
sphincter  muscles  increase  in  strength  with  the  advance  of  age ;  this 
is  one  of  the  causes  why  the  fseces  are  voided  with  more  difficulty  in 
old  persons.  To  give  tone  to  the  rectal  muscles,  astringent  injections 
have  been  recommended  and  extensively  used ;  but  in  my  practice 


412  GENEEAL   TREATMENT   OF   UTEEINE   DISEASE. 

they  have  been  ahuost  uniformly  useless,  many  times  injurious,  and 
always  disagreeable.  They  dry  up  the  secretions,  an  evil  not  to  be 
compensated  for  by  any  other  effect;  they  do  not,  so  far  as  I  can 
judge,  cause  contraction  of  the  muscular  fibres,  but  they  are  very 
apt,  if  persisted  in  for  a  length  of  time,  to  cause  inflammation.  I 
have  derived  more  benefit  from  tonic  suppositories  and  injections 
than  from  any  other  kind  of  medicinal  treatment.  A  suppository 
of  twenty  grains  of  extract  of  gentian,  or  five  grains  quin.  sulph.,  ten 
grains  of  extract  of  cornus  Florida,  or  a  mucilaginous  suspension  of 
any  of  these  introduced  into  the  rectum  every  night  at  bedtime,  and 
retained,  if  possible,  until  morning,  are  good  tonics  and  eligible 
modes  of  using  them.  It  will  be  necessary,  to  secure  the  retention 
and  efficient  contact  of  these  tonics,  to  first  empty  the  bowels  Avith 
ox-gall  and  warm  water,  and  afterward  introduce  them  with  as  little 
irritation  as  possible.  The  quantity  of  mucilaginous  material  should 
not  exceed  two  ounces.  The  tonic  treatment  of  this  kind  must  be 
varied,  taking  first  one  tonic  and  then  another,  in  first  one  form  and 
then  a  different  one,  and  must  be  kept  up  for  a  long  time  to  do  much 
good.  We  cannot  be  too  careful,  in  all  our  treatment,  to  avoid  any- 
thing to  which  the  rectum  shows  any  sensitiveness.  When  it  be- 
comes tender  and  sensitive,  we  should  at  once  desist  until  all  of  this 
has  subsided  before  we  are  justified  in  beginning  again.  It  too  fre- 
quently happens  that  both  the  physician  and  patient  become  dis- 
couraged, and  desist  before  the  remedies  have  had  a  fair  trial.  Is 
there  anything  that  will  relax  the  sphincter  ani?  I  am  not  aware 
that  any  means  operate  with  efficiency  in  this  direction ;  but  I  have 
used,  in  a  few  instances,  with  apparent  benefit,  the  ointment  of  bella- 
donna, made  by  mixing  the  extract  with  lard.  I  apply  it  to  the 
anus  externally  upon  going  to  bed  at  night,  and  continue  it,  until 
the  question  against  or  in  favor  of  its  usefulness  is  fully  determined. 

This  application  certainly  removes  the  irritability  of  the  sphincter, 
which  causes  it  sometimes  to  resist  the  extrusion  of  the  faeces. 

As  I  have  before  remarked,  there  are  cases  in  which  this  relaxation 
cannot  be  cured ;  we  are  then  compelled  to  resort  to  palliatives,  and 
we  must  be  careful  to  palliate  intelligently.  We  are  to  give  the  weak 
rectum  artificial  support,  to  enable  it  to  retain,  as  near  as  may  be,  its 
ordinary  size.  This  can  be  done  only  through  the  vagina.  An  air  or 
sponge  pessary  introduced  into  the  vagina,  so  as  to  press  the  rectum 
against  the  sacrum,  and  thus  diminish  its  capacity,  will  prevent  the 
great  accumulations  from  taking  place,  and  in  that  way  prevent  one 
source  of  great  inconvenience.  Dr.  Hodge  recommends  the  globe 
pessary  for  this  condition  of  the  rectum,  which  answers  very  well  in 
many  cases,  perhaps  in  the  majority ;  but  each  case  must  be  studied 
with  reference  to  its  own  peculiarities,  and  the  shape,  size  and  con- 
sistency of  the  pessary  adapted  to  it. 


CONSTIPATION.  413 

When  our  object  is  palliation  alone,  there  is  no  objection  to  wearing 
the  pessary  all  the  time,  but  if  it  is  used  to  palliate  what  we  believe  to 
be  a  curable  case,  we  ought  to  use  it  intermittingly,  and  the  patient 
should  not  wear  it  at  night,  especially.  It  would  probably  be  better, 
in  a  majority  of  the  cases,  to  introduce  it  before  rising  in  the  morning, 
and  allow  it  to  remain  until  noon.  One  thing  I  think  essential  in  the 
size  and  position  of  the  pessary,  and  that  is,  that  it  does  not  compress 
the  rectum  below  its  natural  capacity ;  there  should  be  room  enough 
for  an  ordinary  amount  of  fseces  in  it,  lest  it  become  a  source  of  ob- 
struction, which  it  will  do  when  larger  or  improperly  placed. 

As  will  be  noticed,  I  have  omitted  to  say  anything  of  enemata  in  con- 
stipation, from  inactivity  of  the  colon  or  upper  portion  of  the  alimen- 
tary canal.  As  an  occasional  means  injections  operate  well ;  but  like 
other  laxatives,  when  used  for  a  length  of  time  they  lose  their  influence 
entirely.  If  we  determine  to  use  injections  as  an  habitual  laxative, 
by  proper  changes  in  kind  and  quantity,  we  may  prolong  their  efficacy 
very  much.  To  a  person  unused  to  them  half  a  pint  of  cold  water  will 
act  very  well.  When  the  bowels  fail  to  res23ond  to  this  quantity  there 
ought  to  be  an  increase  of  two  or  three  ounces,  and  then  that  amount 
used  until  its  effects  are  not  satisfactory,  when  a  few  ounces  more 
should  be  added,  and  so  on  we  may  increase  the  amount  until  the 
quantity  becomes  intolerable.  When  this  is  the  case  we  may  order 
half  a  pint  of  water  with  a  drachm  or  two  of  common  salt,  chlorate 
potassa,  or  nitrate  of  soda  or  potassa.  We  should  increase  the  quan- 
tity of  water,  or  strength  of  solution,  or  both,  as  the  susceptibility  of 
the  rectum  is  decreased,  until  we  cannot  carry  either  farther.  In  very 
obstinate  constipation  the  bowels  may  be  emptied  with  much  cer- 
tainty by  injecting  a  large  quantity  of  water  in  the  knee-chest  posi- 
tion. In  this  position  the  water  will  pass  the  sigmoid  flexure  of  the 
colon  into  the  mass  of  faeces,  softening  it,  and,  by  its  bulk,  stimulate 
the  alimentary  canal  to  expulsive  efforts.  Very  few  cases  will  resist 
this  method  of  administering  enemata.  After  we  have  thus  obtained 
as  much  good  from  injections  as  we  can,  it  is  sometimes  expedient  to 
use  suppositories  as  laxatives.  Suppositories  are  made  of  laxative 
medicines,  or  of  any  other  material.  Compound  extract  of  colocynth 
or  some  other  purgative  extract  may  be  used ;  or  we  may  enclose  in 
some  of  the  extracts  a  dose  of  podophyllum,  or  any  of  the  purgative 
resinoids  or  alkaloids.  These  should  be  retained  until  absorption 
takes  place.  The  common  suppositories  of  soap,  tallow,  wax,  sperm, 
stearin,  etc.,  are  of  the  second  kind.  It  not  unfrequently  happens  that 
the  above  modes  of  using  injections  and  suppositories  may  be  alter- 
nated very  profitably,  the  full  eff'ects  of  each  being  experienced  upon 
their  resumption  after  having  used  the  other  for  a  time.  But  some 
persons  cannot  use  injections ;  the  rectum  is  too  sensitive,  and  attempts 


414  GENERAL,   TREATMENT   OF   UTERINE    DISEASE. 

to  do  so  induce  so  much  irritation  that  they  must  abandon  them.  In 
such  cases  suppositories  are  out  of  the  question. 

This  form  of  rectocele  sometimes  requires  a  resort  to  surgery.  The 
operation  is  detailed  elsewhere. 

I  have  elsewhere  shown  that  the  uterus,  by  its  wrong  position,  some- 
times presses  upon  the  rectum  and  obstructs  the  passage  of  the  fseces. 
This  may  be  effected  by  retroversion  or  prolapse.  The  indication,  of 
course,  is  to  restore  the  uterus  to  its  proper  place,  and  as  we  shall  have 
occasion  to  speak  elsewhere  of  these  difficulties  (malpositions),  I  do 
not  think  it  necessary  to  more  than  mention  them  here. 


CHAPTER   XXII. 

SPECIAL  TREATMENT. 

Baths. 

The  local  treatment  of  inflammation  of  the  cervix  uteri  is  made 
up  of  several  therapeutic  items,  varying  according  to  the  intensity, 
quality,  and  seat  of  disease.  Of  these  there  are,  however,  a  few  that 
are  applicable  to  almost  all  cases ;  hence  their  description,  modes  of 
use,  etc.,  may  be  considered  before  going  farther.  Baths,  injections, 
and  some  minor  remedies  are  of  this  kind.  Water,  when  applied  to 
the  surface,  is  purely  sedative  in  its  effects  if  it  is  of  the  temperature 
of  the  part  on  which  it  is  used.  If  the  bath  is  partial,  the  sedative 
influence  is  for  the  most  part  conflned  or  limited  to  the  part  to  which 
the  application  is  made.  So  with  injections  per  rectum  or  vaginam. 
They  soothe  the  parts  contained  in  the  pelvis.  If  the  water  is  warmer 
than  the  part  of  the  surface  bathed,  the  effect  is  stimulant;  if  it  is 
colder,  by  virtue  of  the  physiological  action  brought  into  play,  it  is 
first  sedative  and  then  stimulant.  The  circulation  and  nervous  influ- 
-ence  of  the  vagina,  for  instance,  when  the  cold  water  is  first  thrown 
into  it,  are  depressed,  but  very  soon  after  its  evacuation,  or  with- 
drawal, the  vessels  become  excited  to  increased  circulation  of  blood, 
and  increased  heat  takes  place  and  the  nerves  become  more  sensitive. 
In  all  these  respects  baths  and  injections  act  alike.  The  injections 
are  internal  baths,  by  which  the  uterus  is  bathed  through  the  vagina. 
But  the  effects  of  baths  and  injections  may  be  modified  by  containing 
medicinal  substances.  They  may  be  rendered  more  stimulant  or 
more  sedative,  or  be  even  made  to  possess  other  qualities  by  impregna- 
tion with  medicines ;  one  in  very  common  use  is  astringent  in  char- 
acter. Another  mode  of  using  water  and  applying  it,  either  simple 
or  impregnated  with  medicine,  is,  to  wet  a  cloth  or  a  sponge  with  it 
and  bind  it  to  the  surface,  or  introduce  it  into  the  vagina.  Several 
thicknesses  of  cotton  cloth  applied  to  the  abdomen  and  impregnated 
with  water  is  what  is  called  the  water  compress;  and  often  when 
allowed  to  remain  in  contact  with  the  skin  for  several  hours  it  pro- 
duces considerable  excitement,  and,  if  persisted  in  for  days,  will 
cause  first  a  vesicular,  next  a  pustular,  and  finally  a  phlegmonous 
eruption.  The  way  to  render  it  effective  is,  after  applying  the  wet 
cloth,  to  cover  it  over  with  oil-silk,  and  then  confine  the  whole  with 
a  bandage  or  roller,  with  a  view  to  prevent  evaporation.  Sponge  in- 
troduced into  the  vagina,  impregnated  with  water  holding  medicine 


416  SPECIAL,  TEEATMENT. 

in  solution,  is  a  common  way  of  affecting  the  uterus.  I  do  not  design 
giving  an  extended  view  of  the  effects  of  baths  or  their  application 
and  modus  operandi,  but  so  much  aid  is  occasionally  obtained  by  the 
use  of  them,  that  I  cannot  refrain  from  speaking  of  the  application  of 
some  forms  of  them  to  diseases  of  the  uterus. 

Hip-bath. 

The  bath  most  applicable  in  inflammation  of  the  cervix  uteri  and 
most  commonly  used  is  the  sitz-  or  hip-bath,  which  is  intended  to 
allay  the  inflammatory  irritation  and  pain.  It  is  often  the  case  that 
there  is  a  great  deal  of  suffering  from  pain  without  much  inflam- 
matory action  in  the  parts ;  in  these  cases  a  sitz-bath  will  often  give 
great  relief.  In  many  instances  the  efficacy  of  the  bath  may  be 
enhanced  by  having  the  patient  introduce  a  speculum  while  in  the 
water,  so  that  it  may  pass  up  the  vagina  to  the  neck  of  the  uterus  and 
thus  directly  affect  the  part  diseased.  In  cases  of  medicated  sitz- 
baths  the  organ  may  thus  receive  the  full  benefit  of  the  saline,  ano- 
dyne, or  other  medicinal  impregnation.  The  common  glass  tube  will 
do  very  well  for  this  use,  where  we  wish  only  to  bathe  the  neck  of  the 
uterus ;  but  if  we  wish  the  fluid  to  come  in  contact  with  the  vaginal 
walls  and  remain  there  for  a  considerable  time,  the  wire  speculum  is 
the  best.  While  speaking  of  the  use  of  the  speculum  in  this  way,  I 
may  mention  that  a  very  efficacious  mode  of  applying  medicated 
washes  without  the  bath  to  the  cervix  uteri  or  vaginal  walls,  is  to 
have  the  patient  lie  upon  her  back,  introduce  the  speculum,  and  then 
pour  the  fluid  into  it.  By  remaining  in  that  position  she  can  retain 
the  contact  of  the  medicated  solution  as  long  as  desirable.  Ice- water, 
ice,  astringent  powders,  or  almost  any  form  of  substance  may  be  ap- 
plied and  retained  in  contact  with  the  os  and  cervix  uteri  with  great 
advantage  in  this  way.  This  mode  of  using  remedies  is  particularly 
useful  in  bleeding  fungus  or  vascular  tumor  of  any  kind. 

The  sitz-bath,  when  a  patient  is  suffering  with  the  pain  and  heat 
of  uterine  disease,  may  be  used  as  often  as  necessary,  twice  a  day  at 
least ;  but  three,  four,  or  even  a  greater  number  of  times  will  not  be 
too  often,  when  they  are  found  to  be  soothing  and  useful.  We  may 
extemporize  a  hip-  or  sitz-bath,  by  putting  water  in  a  common  wash- 
ing-tub; but  the  cheap  tin  vessels  made  for  the  purpose  are  within 
the  command  of  almost  all  persons.  There  should  be  so  much  water 
that  when  the  patient  sits  down  in  it,  the  whole  pelvis  will  be  covered. 

Temperature  of  the  Bath. 

What  should  be  the  temperature  of  the  bath  ?  The  patient's  sense 
of  comfort  or  discomfort  from  its  use  should  be  our  guide  in  thir 
resiDect.     We  should  seek  a  temperature    that  is   comfortable   an 


VAGINAL,    INJECTIONS,    IREIGATION,    DOUCHES.  417 

soothing  to  the  patient  while  in  the  water,  and  that  leaves  no  sense  of 
discomfort.  The  baths  are  intended  for,  and  should  add  to,  the  com- 
fort of  the  patient;  when  they  do  not  do  this,  they  should  at  once  be 
discontinued.  As  a  general  rule  I  advise  my  patient  to  take  tepid 
water  for  her  first  baths,  and  then  gradually  use  them  cooler  until 
they  are  cold,  unless  they  become  disagreeable  in  some  respect;  if 
they  do  so,  to  continue  them  tepid.  The  colder  a  bath  is  the  naore 
good  it  does,  provided  it  be  comfortable.  The  time  for  taking  it  may 
be  regulated  by  the  convenience  of  the  patient,  and  the  necessity  for 
it,  with  the  view  of  allaying  pain,  heat,  etc. ;  probably  in  the  majority 
of  instances,  the  most  advisable  times  for  taking  it  are  upon  rising 
and  retiring.  The  length  of  time  the  patient  remains  in  the  bath 
should  also  be  regulated  somewhat  by  its  effects.  If  the  patient 
remains  too  long  in  the  water  it  will  debilitate  her,  particularly  if 
there  is  considerable  water  and  the  bath  is  frequently  repeated ;  on 
the  other  hand,  if  she  does  not  remain  long  enough,  she  will  not  de- 
rive any  benefit  from  it.  She  may  try  remaining  in  it  fifteen  minutes, 
if  she  does  not  find  herself  very  much  relieved  before  that  time,  and 
she  ought  to  be  governed  in  her  use  of  subsequent  baths  in  this 
particular  by  the  effects-  of  the  first  few  trials.  While  in  the  bath  the 
intended  temperature  of  the  water  may  be  kept  up  by  adding  hot 
water  from  time  to  time.  The  hip-bath  is  used  almost  wholly  with 
reference  to  the  local  disease,  but  when  general  baths  are  required, 
it  is  usually  for  the  relief  of  some  attendant  general  symptom. 

Shower-hath. 

The  shower-bath  may  be  used  as  a  roborant  excitor  of  the  circula- 
tion, if  upon  trial  it  can  be  borne,  and  produce  a  good  effect.  Some 
patients  think  they  are  very  much  benefited  by  the  shower-bath,  and 
say  they  cannot  do  without  it. 

Sponge  Bath. 

The  sponge  bath  is  useful  in  causing  a  tonic  and  soothing  reaction 
upon  the  surface.  Neither  of  these  can  be  tolerated  by  very  feeble 
patients.  The  cold  or  tepid  sponge  bath,  administered  at  bedtime, 
not  unfrequently  soothes  nervous  irritability,  and  enables  restless 
persons  to  sleep  soundly.  I  have  not  used  baths  in  any  other  form 
than  these,  but  when  used  as  I  have  here  indicated,  I  have  seen  such 
pleasant  results  from  them  that  I  cannot  refrain  from  recommending 
them. 

Vaginal  Injections,  Irrigation,  Douches. 

The  modern  methods  and  purposes  of  vaginal  injections  differ  so 
much  from  the  imperfect  ones  used  only  a  decade  since,  as  to  require 
new  means  as  well  as  modes.     In  early  gynecology  we  satisfied  our- 

27 


418 


SPECIAL   TREATMENT. 


selves  with  the  glass  or  hard  rubber  instruments,  not  much  longer 
than  a  man's  finger.  Another  step  toward  the  present  condition  of 
things  brought  us  the  soft  rubber  tube  of  some  length,  and  a  bulb 
with  which  to  keep  up  a  perpetual  stream.  This  was  a  laborious  in- 
strument, and  required  strong  muscle  to  use  it.  Next  came  the 
fountain  syringe,  holding  a  quart  at  first,  afterwards  two  quarts.  This 
was  a  labor-saving  machine,  and  was  an  approach  to  luxury  in  the 
use  of  douches.  During  all  this  time  the  patient  took  her  injections 
in  the  sitting  posture.  Now  the  fountain  has  grown  to  great  dimen- 
sions, holding  gallons,  and  it  is  indispensable  that  the  patient  assume 
the  dorsal  recumbent  position,  which  necessitates  the  douche-pan  and 
slop-bucket. 

Fig.  202. 


Vaginal  Douches. 


At  first  the  purpose  was  to  medicate  the  vagina  and  cervix ;  after- 
wards to  cleanse,  or  medicate,  or  both.  Now  the  purpose  is  to  treat 
the  parts  to  a  very  hot  bath,  with  the  object  of  stimulating  the  capil- 
laries of  the  mucous  surfaces,  causing  their  contraction,  and  restricting 
the  flow  of  blood  to  the  inflamed  parts,  and  to  influence  the  deeper 
tissues  by  a  similar  effect  upon  their  capillaries.  This  amounts  to  a 
valuable  alterative  to  the  parts  within  reach  of  the  effect  of  the  heat 
in  the  water.     The  influence  of  the  hot  water  when  the  patient  is  lying 


ACCIDENT   IN    INJECTION.  419 

on  her  back,  is  complete  by  filling  the  vaginal  cavity  and  keeping  it 
so  by  furnishing  a  continuous  supply  from  the  fountain  as  long  as  is 
desirable.  Injections,  or  more  properly,  douches,  of  hot  water  are 
applicable  to  a  large  variety  of  cases — chronic  inflammation  in  the 
vagina  and  cervix,  and  cases  of  inflammatory  exudation  in  the  pelvic 
tissues  outside  the  uterus.  In  acute  cases  of  inflammation  this  hot 
water  cannot  generally  be  borne ;  and  many  patients  cannot  tolerate 
it  even  when  the  conditions  indicating  it  seem  to  be  present,  probably 
on  account  of  some  peculiar  susceptibility.  Some  patients  will  profit 
by  a  small  amount  of  hot  water  and  sufi'er  from  the  large  douche. 
Others  will  be  comforted  and  improved  by  the  use  of  tepid  water  in 
large  or  small  quantities,  who  cannot  use  the  hot.  The  apparatus  for 
using  the  douche  consists  of  two  pieces,  a  large  reservoir  of  tin  or 
rubber,  and  a  douche-pan.  The  douche-pan  may  be  made  of  rubber, 
tin,  or  earthen  material,  and  resembles  an  ordinary  bed-pan  furnished 
with  an  outlet  tube  to  carry  the  water  into  a  bucket,  basin,  or  other 
receptacle. 

These  large  douches  are  used  twice  a  day  or  oftener  as  they  may 
appear  to  be  useful  or  not. 

Accident  in  Injection. 

There  is  one  annoying,  and  sometimes  to  the  patient  alarming, 
little  accident  that  occasionally  occurs  during  the  reception  of  an  in- 
jection in  the  vagina.  Suddenly,  while  injecting  the  fluid,  she  is 
seized  with  severe  cramping  pain  in  the  hypogastric  region,  which 
radiates  to  the  back  and  hips,  down  the  thighs,  and  sometimes  over 
the  whole  abdomen.  She  becomes  sick  at  her  stomach,  is  attacked 
with  rigors,  and  her  feet  and  hands  often  become  cold.  This  pain 
continues,  with  exacerbations  and  remissions,  for  several  minutes  or 
hours,  and  when  it  subsides,  leaves  a  sense  of  soreness,  more  or  less 
considerable,  corresponding  with  the  severity  of  the  attack.  As  the 
chilliness  and  rigors  of  the  first  few  moments  subside,  there  is  reac- 
tion ;  the  patient  becomes  warm,  and  sometimes  decidedly  feverish. 
In  all  cases  in  which  I  have  witnessed  these  symptoms  the  patients 
were  using  a  syringe  in  the  end  of  which,  within  the  vagina,  were 
several  perforations,  some  on  the  side  of  the  bulb  at  the  end,  and  one 
at  the  very  extremity.  I  think  that  one  of  the  perforations  had  been 
accidentally  placed  in  opposition  with  the  external  os  uteri,  and  as  the 
water  was  forced  through  this  perforation,  it  entered  the  cavity  of  the 
cervix,  and  passed  through  into  the  cavity  of  the  body  of  the  uterus, 
inducing  the  first  shock,  and  the  pains  following  it  were  caused  by  the 
spasmodic  attempts  on  the  part  of  the  uterus  to  expel  it.  Although 
I  have,  in  a  large  number  of  instances,  been  called  upon  to  witness 
and  prescribe  for  these  symptoms,  I  have  not  seen  them  proceed  to 
dangerous  extremities.     I  think  these  are  cases  of  injection  into  the 


420  SPECIAL  TEEATMENT. 

womb;  and,  in  this  respect,  the}^  constitute  my  whole  observation. 
An  opiate  injection  per  rectum,  fomentations  over  the  pubis,  and 
quiet,  are  all  the  remedies  I  have  found  necessary.  And  often  the 
symptoms  subside  so  soon  that  I  have  not  been  under  the  necessity  of 
prescribing  at  all. 

We  occasionally  meet  with  patients  who  cannot  use  baths  or  injec- 
tions. In  these  cases  it  will  be  found,  almost  invariably,  that  this 
inability  arises  from  their  producing  an  exaggerated  effect.  If  it 
is  simple  tepid  water  used  for  the  bath  or  injection,  its  results  are  too 
sedative.  The  bath  debilitates  the  patient,  instead  of  simply  sooth- 
ing her.  I  have  seen  a  single  tepid  bath  prostrate  a  patient  so  that 
she  would  have  to  lie  in  bed  for  several  hours  before  its  effects  wore 
off.  A  cold  bath  induces  chilliness  and  permanent  coldness,  and  re- 
action is  not  established;  the  system  recovers  from  its  effects  only 
after  a  number  of  hours,  and  that  slowly.  Hip,  sitz,  or  general 
baths  may  produce  these  effects,  and  when  they  do  so,  should  be 
abandoned  as  injurious.  Other  nervous  symptoms,  as  difficulty  of 
breathing,  nausea,  dysuria,  etc.,  also  occasionally  seem  to  be  the 
effects  of  baths.  It  is  singular  that  some  patients  are  so  susceptible 
to  the  depressing  effects  of  water  that  injections  debilitate  them  very 
rapidly,  and  they  are  obliged  to  abandon  them  on  this  account.  Cold 
water,  as  an  injection,  not  unfrequently  causes  general  coldness.  But 
it  is  the  medicated  injections  that  most  frequently  produce  an  exag- 
gerated effect.  Alum  injections,  even  when  the  solution  is  weak,  with 
some  patients,  produce  such  disagreeable  and  constant  dryness,  and 
sense  of  heat,  as  to  make  them  quite  intolerable.  And  the  sensitive- 
ness of  the  vagina  becomes  so  great  that  some  patients  are  forced  to 
cease  the  injections  of  alum  wholly.  The  same  objections  apply  to 
other  astringents  to  a  less  degree,  and  the  consequence  is,  that  how- 
ever baths  and  injections  may  seem  to  be  indicated,  in  the  cases  where 
idiosyncrasy  renders  them  so  objectionable,  we  must  forego  their  use 
entirely. 

Should  they  be  used  in  Pregnancy  f 

Is  pregnancy  an  objection  to  the  use  of  local  baths  and  injections? 
I  think  not  with  proper  care.  A  hot  bath  about  the  hips  would  be 
objectionable ;  a  very  cold  bath  that  might  cause  much  of  a  shock,  or 
internal  congestions,  would  not  be  advisable ;  but  plenty  of  tepid 
water,  and  even  cool  water,  temperately  used  as  baths,  give  the  preg- 
nant woman  great  comfort,  and  cannot  generally  be  followed  by  any 
bad  effect.  Injections  may  be  used  with  less  caution  than  baths.  The 
caution  which  we  would  administer  to  all  is,  that  they  should  not  be 
copious.  In  pregnancy  the  patient  ought  not  to  use  more  than  a 
quart  at  one  time.  The  injections  should  always  be  tepid  or  cool  ,* 
not  very  cold  or  very  warm,  lest  they  stimulate  the  muscular,  vascu- 


INJECTIONS    IN    PEEGNANCY.  421 

lar  or  nervous  system  of  the  uterus  too  much,  and  induce  hemorrhage, 
or  provoke  contractions.  Both  of  these  effects,  I  think,  I  have  known 
produced  by  such  injections  ;  the  cold  causing  contraction  and  expul- 
sion ;  and  the  very  warm  hemorrhage  and  death  of  the  ovum.  Strong 
astringents  should  also  be  avoided.  Much  comfort  may  be  derived 
from  anodyne  injections,  when  there  is  neuralgic  suffering  about  the 
uterus  or  vagina,  during  pregnancy.  Cases  of  superficial  inflamma- 
tion, and  even  early  ulceration  of  the  vaginal  portion  of  the  cervix, 
may  always  be  benefited  by  injections,  baths,  and  the  general  treat- 
ment which  I  have  heretofore  detailed.  In  fact,  most  cases,  if  not  all, 
where  there  is  no  idiosyncratic  objection  to  the  baths  and  injections, 
will  be  very  much  benefited  by  them.  When,  however,  the  disease 
has  been  of  long  standing,  or  extends  between  the  labia  of  the  os  uteri, 
or  into  the  cavity  of  the  cervix,  these  will  only  slightly  benefit  it.  We 
must  then  seek  for  something  that  will  more  profoundly  influence 
the  nutritional  changes,  and  the  vascular  and  nervous  tissues  of  the 
parts. 

The  introduction  of  anodyne,  astringent  and  alterative  ointments, 
pessaries  and  powders  may  be  resorted  to  with  much  profit  in  many 
instances.  The  small  instrument  called  the  suppository  syringe  will 
enable  the  patient  to  place  ointment  in  contact  with  the  uterus  very 
conveniently.    Ointments  made  with  opium,  belladonna,  hyoscyamus, 

Fig.  203. 


Ointment  Syringe. 


cicuta,  tannic  acid,  mercury,  iodine — in  fact,  almost  an}^  substance 
used  to  exert  an  influence  locally — may  be  made  into  ointment  and 
thus  introduced.  The  powders  of  many  of  these  articles  may  be 
deposited  in  the  vagina  in  the  same  way.  And  the  medicated  pes- 
saries made  by  mixing  the  medicine  intended  to  be  used  with  cacao- 
butter,  may  be  passed  up  to  the  os  uteri  through  a  glass  speculum, 
either  by  the  patient,  her  attendants,  or  the  physician.  In  using  the 
narcotics  in  the  vagina,  in  the  form  of  ointment  or  pessary,  we  can 
safely  use  double  the  quantity  given  by  the  stomach.  The  ointment 
is  absorbed  slowly,  and  consequently  it  requires  some  time  to  effect 
much  by  it.  But  the  powders  act  much  more  readily.  Morphia  thus 
introduced  will  sometimes  act  with  great  promptitude,  and  the  powder 
of  tannic  acid  is  a  very  efficient  astringent  used  in  this  way.  The 
absorbing  power  of  the  vaginal  mucous  membrane  is  decidedly  less 
than  that  of  the  rectum.  It  takes  a  longer  time  and  more  of  the  medi- 
cine to  affect  the  system  through  this  cavity.  Possibly  this  may  be 
to  some  extent  on  account  of  the  more  ready  escape  of  substances 


422  LOCAL   TREATMENT. 

from  the  vagina ;  but  I  think,  also,  the  membrane  does  not  take  up 
substances  so  quickly.  From  this  fact  injections  or  suppositories  per 
rectum  will  often  do  more  good  in  allaying  pain  esi3ecially  than  when 
used  per  vaginam.  A  few  drops  of  strong  solution  of  morphia  sulph.  in 
the  rectum  act  very  promptly.  Dr.  Greenhalgh  and  others  use  cotton 
pessaries  medicated,  per  vaginam.  The  cotton  is  prepared  by  immers- 
ing it  in  a  strong  solution  of  the  medicinal  agent  to  be  employed,  and 
afterward  drying  before  using  it.  Still  another  method  of  making 
local  applications  to  the  upper  part  of  the  vagina  is  to  envelop  the 
medicines  in  a  sac  of  thin  cotton  or  linen  goods,  and  pass  it  up  to  the 
cervix,  and  let  it  remain  there  until  the  astringent,  or  whatever  may 
be  contained  in  it,  is  dissolved  out,  and  exerts  its  influence  upon  the 
parts.  The  patient  can  use  this  kind  of  application  without  assist- 
ance. 

LOCAL  TREATMENT. 

There  are  very  few  cases  of  chronic  inflammation  and  congestion  of 
the  uterus  that  may  not  be  benefited  by  what  is  known  as  local  treat- 
ment. This  is  especially  true  with  reference  to  those  cases  in  which 
the  intensity  of  the  disease  is  sufficient  to  cause  the  loss  of  the  epithe- 
lium or  deeper  portions  of  the  mucous  membrane, — abrasion  or  ulcera- 
tion. Local  treatment  is  not  only  beneficial  but  indispensable  to  the 
cure  of  endometritis  and  endocervicitis. 

Local  treatment  consists  in  the  application  of  certain  medicines  di- 
rectly to  different  parts  of  the  uterus  and  vagina  for  the  relief  of  the 
various  conditions  connected  with  the  inflammation.  The  medicines 
and  the  methods  of  their  application  are  intended:  first,  to  relieve 
pain  by  their  anodyne  influence;  second,  to.  deplete  the  parts  of  the 
superabundance  of  blood ;  and,  third,  to  change  the  character  of  the 
capillary  circulation  by  restoring  its  natural  activity. 

When  there  is  much  pain  of  whatever  character  the  anodyne  appli- 
cations are  indicated ;  and  many  patients  will  bear  anodynes  as  local 
applications  for  the  relief  of  pain  very  much  better  than  when  taken 
internally.  Even  where  there  is  no  idiosyncrasy  forbidding  the  use 
of  anodynes,  they  may  affect  the  stomach  on  account  of  their  taste,  so 
that  they  cannot  be  borne  or  will  not  be  taken. 

Suppositories  made  by  impregnating  cacao-butter  with  a  quantity 
of  the  anodyne  to  be  made  fifty  per  cent,  larger  than  when  taken  in 
the  stomach,  and  repeated  as  frequently  as  required,  is  one  method 
of  making  anodyne  applications.  The  suppositories  are  made  by  the 
apothecary  in  a  shape  and  of  a  size  for  the  vagina,  and  also  for  the 
rectum.  It  requires  a  longer  time  for  the  anodyne  to  be  absorbed  by 
the  vaginal  membrane  than  by  the  stomach  or  rectum. 

When  it  is  desired  to  use  the  suppositories  in  the  rectum  instead 


LOCAL    TREATMENT.  423 

of  the  vagina,  it  will  require  no  more  than  the  ordinary  dose  of  the 
medicine,  and  the  effect  is  obtained  more  promptly.  It  must  be  re- 
membered also  that  the  mucous  membrane  of  the  rectum  is  very  much 
more  sensitive  than  that  of  the  vagina.  When  therefore  we  desire  to 
use  medicines,  the  primary  effect  of  which  is  irritation,  as  chloral  or 
bromides,  it  will  be  necessary  to  dilute  them  more  than  for  the  vagina. 
Topical  applications  of  anodynes  may  be  made  in  various  other  ways, 
by  inclosing  the  medicines  in  a  sac  of  thin  cotton  cloth,  gauze,  or  do- 
mestic, and  placing  it  in  the  uj^per  part  of  the  vagina,  or  entangling 
it  in  cotton-wool  and  putting  it  near  the  cervix. 

Sometimes  the  medicine  may  be  apj^lied  in  solution,  the  patient 
lying  on  her  back  so  that  the  fluid  may  gravitate  to  the  cervix.  Half 
an  ounce  of  fluid  introduced  through  an  ordinary  glass  or  rubber 
syringe  will  generally  be  retained — if  the  patient  continues  the  dorsal 
position — until  it  affects  the  nerves  of  the  part.  Applications  of  this 
kind  can  be  made  by  the  patient  herself,  or  the  nurse. 

Topical  depletion  in  inflammation  and  congestion  of  the  uterus  is 
also  a  most  valuable  curative  measure.  When  the  uterus  is  very 
tender  and  sensitive  to  the  touch,  it  will  require  but  little  irritation 
to  cause  intense  local  inflammation.  We  must  be  especially  careful 
under  such  circumstances  to  avoid  the  third  class  of  topical  applica- 
tions. 

The  tenderness  and  sensitiveness  depend  upon  an  unusual  intensity 
of  inflammation  in  the  fibrous  structure  of  the  uterus  above,  which, 
although  chronic  in  duration,  is  subacute  in  grade.  The  kind  of 
turgidity,  sensitiveness,  and  pain  is  sometimes  kept  up  by  the  jDres- 
ence  of  perimetric  inflammation — cellulitis — local  peritonitis,  cystitis, 
etc.,  and  they  contraindicate  any  stimulating  applications  to  the 
uterus.  It  is  in  the  conditions  just  described  that  local  depletion  is 
applicable  and  beneficial.  Common  means  of  local  depletion  are 
leeches  and  scarification.  Leeches  may  be  applied  directly  to  the 
uterus  through  the  speculum,  around  the  anus,  over  the  sacrum  or 
pubic  region.  When  we  desire  to  apply  them  to  the  cervix,  some 
preparation  will  be  necessary  to  insure  success.  The  vagina  must  be 
thoroughly  washed  by  large  injections  of  hot  water  to  remove  any 
offensive  secretion  or  other  contents  of  the  vagina.  The  cervix  may 
then  be  exposed  by  the  speculum  and  sponged  with  sugar  and  milk, 
and  it  will  add  to  the  readiness  with  which  the  leeches  take  hold  to 
prick  the  cervix  until  it  bleeds,  and  then  smear  the  surface  with  the 
blood.  The  leeches  are  first  thrown  into  tepid  water,  and  from  it  are 
taken  out,  placed  in  contact  with  the  cervix,  and  watched  until  they 
fasten  upon  it.  The  number  employed — from  four  to  twelve — will 
be  governed  by  the  amount  of  turgescence  and  pain ;  when  the  in- 
tensity of  inflammation  is  very  considerable,  the  greater  number.  In 
judging  of  the  number  necessary,  we  must  be  governed  by  the  pain, 


424  LOCAL   TREATMENT. 

tenderness,  and  general  condition  of  the  patient.  The  pain  and 
tenderness  must  be  such  as  are  caused  by  local  hypersemia — inflam- 
matory or  congestive — or  by  inflammation  in  the  surrounding  tissue, 
and  not  the  pain  and  sensitiveness  of  neurotic  conditions  of  the  parts 
or  the  patient.  I  do  not  mean  neuralgic  pain  as  that  term  is  generally 
understood,  but  hypersesthesia  unattended  by  any  hypersemia. 

Scarification  cannot  be  made  to  take  the  place  of  leeches,  but  it  is 
often  followed  by  great  improvement,  and  is  very  efficient  in  remov- 
ing congestion  of  the  submucous  tissues.  It  maiy  be  performed  by 
any  long  pointed  knife  by  which  the  cervix  can  be  reached,  but 
perhaps  the  more  efficient  instrument  is  Buttle's  artificial  leech.  It 
is  a  very  small  spear-shaped  knife  mounted  upon  a  long  shank  and 
handle  (Fig.  205).  With  these  instruments,  the  most  dependent  parts 
of  the  cervix  may  be  pricked  in  several  places.  The  bleeding  may  be 
encouraged  by  injections  of  tepid  water  in  large  quantities. 

Fig.  204. 


Knife  for  Scarifying  the  Cervix. 

In  what  time  of  the  month  is  depletion  the  most  useful  ?  Before 
the  commencement  of  the  flow,  as  a  rule,  there  is  the  greater  amount 
of  hypersemia,  and  consequently  is  the  time  we  might  effect  the  most 
good  from  depletion.  This  is  not  always  the  case,  however.  There 
is  no  question  that  patients  who  have  febrile  excitement  during  the 
time  of  the  antemenstrual  congestion  are  very  much  benefited  by 
local  depletion  at  that  time,  but  much  more  frequently  the  cases  of 
lingering  congestion  will  require  it  oftener. 

When  the  menstrual  flow  is  deficient  and  the  uterus  is  not  relieved 
by  it,  many  women  are  relieved  by  leeching  or  scarifying  the  cervix. 

The  congestion  which  lingers  after  the  menstrual  period  and  causes 
so  much  suffering,  is  generally,  although  not  always,  the  result  of  a 
very  scanty  flow.  In  either  case,  when  we  determine  to  deplete,  it 
should  be  done  as  early  as  the  close  of  the  flow,  at  latest,  and  if  the 
flow  is  scanty  during  the  discharge. 

Independent  of  these  physiological  reasons  for  selecting  these  times 
for  depletion,  and  notwithstanding  the  fact  that  thus  used  the  deple- 
tion is  generally  attended  with  the  best  results,  the  very  best  rule  for 
our  guide  will  be  found  in  the  symptoms.  In  most  cases  there  is  a 
particular  time  in  the  month  when  the  symptoms  are  the  greatest  in 
intensity ;  that  is  the  time  to  deplete.  In  some  this  intensity  occurs 
before,  in  others  during  or  immediately  after,  the  flow,  while  in  still 
another  class  of  patients  it  is  midway  between  the  periods.  Rarely 
there  are  chronic  cases  where  the  congestive  or  inflammatory  symp- 


LOCAL   TREATMENT.  425 

toms  last  all  the  time.    When  there  is  enough  general  vigor,  these 
will  be  improved  by  depletion  two  or  three  times  a  month. 

In  connection  with  the  measures  for  depletion,  glycerin  deserves 
to  be  mentioned.  When  placed  in  contact  with  the  surface  of  the 
body,  its  strong  affinity  for  water  attracts  the  serum  of  the  blood  from 
the  capillary  bloodvessels  very  rapidly.  This  process  is  very  much 
more  active  in  the  vaginal  cavity,  where  the  air  is  to  a  great  extent 
excluded,  as  the  whole  capacity  of  the  glycerin  to  take  up  moisture 
is  exerted  upon  the  membrane  by  which  it  is  surrounded,  and  a  large 
quantity  of  serum  is  rapidly  abstracted  from  the  diseased  parts.  The 
tumefaction  and  tension  are  at  once  removed  and  the  pain  relieved. 

When  a  glycerin  tampon  is  placed  in  the  upper  part  of  the  vagina, 
it  requires  but  a  few  minutes  to  establish  a  copious  watery  discharge, 
that  lasts  until  the  glycerin,  diluted  with  several  times  its  own  weight 
of  serum,  is  washed  out  and  exhausted. 

The  relief  which  follows  this  application  of  glycerin  is  often  even 
more  marked  than  after  depletion  by  leeches.  Glycerin  was  first 
used  as  a  dressing  in  vaginal  operations  by  Dr.  Sims,  and  it  required 
but  a  little  time  for  him  to  discover  its  valuable  properties  as  a  means 
of  relieving  inflammation  and  congestion.  Used  in  this  way  I  con- 
sider glycerin  invaluable.  As  a  lubricant  or  solvent  for  local  appli- 
cations I  believe  it  to  be  worse  than  useless.  To  dissolve  medicine 
in  it,  and  then  apply  it  to  the  cervix,  is  to  insure  the  rapid  removal 
,of  the  medicine  by  a  current  of  serum  poured  out  from  the  surface. 
For  this  reason  absorption  from  a  glycerin  solution,  applied  to  the 
vaginal  surface,  is  simply  impossible.  The  efficacy  of  glycerin  appli- 
cations depends  very  much  upon  their  preparation  and  the  method  of 
using  them. 

The  best  quality  of  cotton  batting  is  the  substance  most  appropriate 
with  which  to  make  glycerin  applications.  There  is  a  great  differ- 
ence in  the  grades  of  cotton  batting  in  the  market,  and  we  should  be 
careful  to  get  the  best  article  made.  It  absorbs  a  larger  quantity  of 
glycerin,  and  does  not  wad  up  into  such  a  compact  mass  as  an  in- 
ferior article  does.  In  preparing  the  glycerin  cotton  for  use,  it  should 
be  made  into  a  round  ball,  about  an  inch  and  a  quarter  in  diameter, 
when  loosely  pressed  in  the  hand.  This  may  be  secured  by  passing 
a  strong  thread  around  it,  having  the  thread  long  enough  to  bring 
out  of  the  vagina,  so  that  the  patient  may  be  able  to  remove  it ;  or 
the  cotton  may  be  rolled  into  the  shape  of  a  cylinder,  two  inches  long, 
and  one  in  diameter,  and  secured  bj^  a  thread.  Every  piece  to  be 
used  should  be  thoroughly  saturated  with  the  glycerin.  It  is  not 
sufficient  to  impregnate  the  surface  of  the  cotton  ball  with  the  medi- 
cine, but  every  fibre  should  be  saturated  with  it.  This  requires  some 
time  to  accomplish,  and  it  will  be  well  for  office  use  to  submerge  the 
cotton  in  a  jar  of  glycerin  and  let  it  lie  until  it  becomes  saturated. 


426  LOCAL  TREATMENT. 

When  we  use  these,  if  they  are  thus  saturated,  they  may  be  gently 
pressed  until  the  glycerin  will  not  flow  from  their  surface. 

The  speculum  will  be  necessary  to  a  perfect  application  of  glycerin, 
and  the  cotton  must  be  placed  in  contact  with  the  diseased  surface. 
One  or  more  of  these  pieces  may  be  applied  according  to  the  capacity 
of  the  vagina  or  the  amount  of  congestion.  Glycerin  thus  used  may 
be  applied  every  third  day,  and  if  the  cotton  is  well  saturated,  allowed 
to  remain  twenty-four  hours,  when  it  should  be  removed. 

Cotton  treated  with  glycerin  in  this  way  is  not  fit  for  a  support  to 
a  displaced  uterus,  and  too  frequent  use  of  these  applications  is  occa- 
sionally followed  by  a  sensitiveness  of  the  mucous  membrane  that 
renders  them  intolerable. 

It  is  not  often  that  we  rely  upon  glycerin  applications  for  a  cure, 
or  even  as  the  principal  remedy.  It  is  more  commonly  used  as  an 
adjuvant  or  a  palliative  measure  to  follow  stronger  applications. 
When  we  are  under  the  necessity  of  making  a  strong  application  to 
the  cervix  and  vagina,  to  follow  it  immediately  by  glycerin  prevents 
the  severe  consequences  that  sometimes  follow. 

Local  Alteratives. 

The  many  remedies  applied  to  the  inflamed  and  abraded  surfaces 
of  the  cervix,  while  they  fulfil  the  general  indication  of  changing  the 
action  of  the  nerves  and  vessels  of  the  parts  to  which  they  are  applied, 
their  special  effects  are  not  precisely  the  same.  There  is  certainly  a 
wide  difference  between  the  local  effects  of  tannin  and  nitric  acid,  of 
tincture  of  iron  and  nitrate  of  silver.  Yet  we  find  them  all,  and 
many  others,  used  in  the  same  kind  of  cases,  one  or  two  of  them  re- 
garded as  quite  sufficient  to  cure  a  large  majority  of  cases.  This  is 
the  case  with  iodine,  carbolic  acid,  and  nitrate  of  silver.  The  prac- 
tice of  experienced  gynecologists,  in  the  use  of  these  local  remedies, 
is  remarkable  in  the  fact  that  a  very  few  can  agree  upon  the  same 
articles.  To  the  inexperienced  this  is  perplexing ;  but  it  is  account- 
able for  by  the  consideration  that  anything  which  will  excite  the 
vasomotor  nerves  sufficiently  to  increase  the  sluggish  capillary  circu- 
lation,—an  essential  item  in  the  process  of  congestion  and  inflamma- 
tion,— will  induce  a  change  in  the  morbid  tissue  to  which  it  is  applied. 
Astringents,  stimulants,  caustics,  etc.,  have  this  effect,  and  so  will  the 
mechanical  influence  of  friction  or  pressure.  This  consideration  does 
not  justify  indifference  as  to  the  choice  of  local  applications,  for  there 
are  other  differences  than  degrees  of  intensity  in  their  action.  There 
is,  therefore,  room  and  reason  for  selections,  which  will  give  quite  a 
range  in  our  choice.  We  should  continually  bear  in  mind  that  all 
irritants  applied  to  the  cervix  as  local  applications,  produce  their 
effect  upon  the  vasomotor  nervous  system  primarily,  and,  secondarily, 
upon  the  circulatory  and  absorbent  functions  of  the  vascular  system, 


LOCAL  ALTERATIVES.  427 

and  that  in  consequence  of  the  unity  of  the  vasomotor  nervous  appa- 
ratus of  the  cervix  and  body  of  the  uterus,  any  impression  made  upon 
the  neck  is  reflected  upon  the  body,  and  conversely.  The  reflected 
influence  is  felt  not  only  upon  the  vessels,  but  also  upon  the  fibrous 
structure  of  the  uterus.  This  explains  the  effects  of  therapeutical 
measures  applied  to  the  cervix. 

There  are  also  certain  remedies  which,  when  applied  to  the  cervix, 
exert  an  influence  through  the  blood.  Mercury  and  iodine  are  un- 
questionably absorbed,  and  they  may  have  a  double  influence  upon 
the  local  disease,  first,  by  the  direct  stimulating  efl'ect  upon  the  nerves 
of  the  part,  and  secondly,  by  their  well-known  general  alterative  in- 
fluence. I  have  several  times  seen  a  marked  ptyalism  follow  a  single 
moderate  local  application  of  the  solution  of  pernitrate  of  mercury, 

Fig.  205. 


Dr.  Buttle's  Uterine  Scarificator  and  Leech,  very  efficient  and  convenient  for  abstracting 
blood  from  the  engorged  cervix  uteri. 

and  it  is  not  an  uncommon  thing  for  patients  to  complain  of  a  me- 
tallic taste  in  the  mouth  in  a  very  short  time  after  an  application  of 
iodine  or  mercury.  When  thus  they  obviously  enter  the  circulation, 
they  may  be  expected  to  exert  the  same  influence  upon  the  effusion 
in  the  substance  of  the  cervix  and  body  of  the  uterus  as  if  taken 
internally. 

Locally  iodine,  in  the  form  of  the  ordinary  tincture,  Churchill's 
tincture,  and  other  alcoholic  solutions,  is  a  very  strong  stimulant,  and 
is  scarcely  caustic  in  any  of  these  solutions.  It  is,  therefore,  in  these 
forms,  an  excellent  application  when  we  desire  to  produce  a  strong 
but  superficial  effect  upon  the  mucous  membrane  of  the  vagina,  cervix, 
or  cervical  cavity,  and  should  not  be  repeated  often.  A  solution  made 
by  dissolving  one  part  each  of  iodine  and  iodide  of  potassium  in  one 
part  of  alcohol  makes  a  very  efficacious  application,  made  by  a  swab 
once  in  a  week  or  ten  days  to  the  erosions  of  the  cervix,  connected 
or  not  connected  with  laceration.  Applied  in  this  way  they  excite 
the  capillary  circulation  of  the  whole  uterus  to  recuperative  activity, 
and  thus  cure  up  the  erosions  and  cause  the  absorption  of  the  deposit 
in  the  areolar  tissue.  Iodine  again  is  used  in  a  different  way  and  for 
another  purpose;  that  is,  in  a  non-irritating  form,  in  which  it  may 
be  absorbed  and  expend  its  influence  as  an  alterative  through  the 
circulation.  It  is  often  dissolved  in  glycerin  and  applied  on  cotton 
to  the  cervix.  The  solution  of  iodine  in  glycerin  for  an  apj^lication 
is  almost,  if  not  entirely,  useles-s,  so  far  as  the  iodine  is  concerned,  for 
it  is  very  soon  washed  out  of  the  vagina  by  the  serum  drawn  from 
the  parts  by  the  glycerin. 


428  LOCAL,  TREATMENT. 

The  very  iDest  way  to  obtain  the  fullest  alterative  effects  of  iodine  as 
a  vaginal  application  is  to  impregnate  cotton-wool  with  iodine  by 
mixing  the  crystals  of  iodine  with  the  cotton,  and  then  placing  them 
in  a  well-stoppered  bottle  in  a  moderately  warm  place,  when  the 
iodine  will  become  volatilized  and  diffuse  itself  thoroughly  and  uni- 
formly in  the  cotton.  This  cotton  may  be  applied  through  the  specu- 
lum to  the  cervix,  and  allowed  to  remain  there  for  twenty -four  hours. 
This  application  may  be  used  every  fourth  or  fifth  day. 

It  is  a  very  common  practice  to  combine  iodine  and  other  medi- 
cines for  local  applications.  Iodine  and  carbolic  acid,  called  iodized 
phenol,  are  combined  in  the  proportion  of  one  part  of  iodine  to  four 
parts  of  carbolic  acid.  This  mixture  is  a  favorite  one  with  Dr.  Robert 
Battey,  of  Rome,  Georgia.  He  has  written  an  able  paper,^  detail- 
ing its  effects  in  endometritis.  His  endorsement  of  it,  as  a  local  appli- 
cation in  this  form  of  disease,  is  a  sufficient  guarantee  of  its  useful- 
ness. 

The  solution  of  pernitrate  of  mercury  ^acid  nitrate  of  mercury),  be- 
cause of  its  valuable  alterative  influence,  deserves  particular  notice. 
Unlike  iodine,  it  is  strongly  caustic  and  can  be  made  to  destroy  the 
parts  to  a  great  depth.  In  this  respect,  perhaps,  it  is  about  equal  to 
nitric  acid.  The  application  of  these  remedies,  however,  can  be  made 
without  destroying  the  tissues ;  and  now  that  we  know  the  salutary 
influence  of  our  applications  does  not  dej^end  upon  "  burning  off  the 
ulcer,"  or  cauterizing  the  abrasion,  but  that  their  efficacy  depends 
upon  the  excitation  they  produce  upon  the  submucous  vessels,  these 
medicines  are  used  very  differently. 

The  acid  nitrate  of  mercury  should  be  applied  by  the  cotton  swab 
so  lightly  as  not  to  cauterize.  The  cotton  should  be  dipped  into  the 
mercury  solution  and  saturated  with  it,  and,  before  being  applied, 
pressed  firmly  between  two  wooden  surfaces  until  it  is  merely  moist 
with  the  solution.  The  cotton  thus  pre23ared  is  applied  to  the  surface ; 
it  coagulates  the  mucus  on  the  surface  merely.  The  application  in  a 
few  hours  is  followed  by  local  reaction  in  the  capillaries  immediately 
beneath  the  part,  which,  in  a  certain  degree,  is  salutary.  It  is  not 
best  to  use  this  for  congestion  or  inflammation,  attended  or  not  with 
abrasion,  oftener  than  once  in  two  weeks  or  a  month.  The  second 
day  after  the  menses  is  the  best  time.  Carbolic  acid,  in  solutions  of 
various  strength,  is  a  popular  remedy  for  local  application  to  the 
cervix  uteri.  The  95  per  cent,  solution  is  equal  in  stimulating  influ- 
ences to  that  of  the  nitrate  of  silver  of  20  per  cent,  strength.  If  used 
exclusively,  or  as  the  main  article,  for  stimulating  the  inflamed  cervix, 
it  may  be  applied  once  a  week. 

*  Read  at  the  meeting  of  the  British  Medical  Association  for  1879,  lield  at  Cork, 
Ireland. 


TREATMENT    OF    ENDOMETRITIS.  429 

Among  the  astringents  the  preparations  of  iron,  solution  of  the  per- 
sulphate and  the  tincture  of  iron  are  frequently  used.  The  tincture 
of  iron,  once  in  five  or  six  days,  is  very  generally  used  with  great 
benefit. 

The  nitrate  of  silver,  once  so  popular  as  a  topical  application,  has 
fallen  into  disrepute,  and  is  seldom  resorted  to  by  our  best  gynecolo- 
gists. The  main  objections  to  it  are  the  great  pain  it  often  produces, 
the  intensity  of  the  submucous  capillary  excitement  it  causes,  which 
sometimes  extends  to  the  cellular  tissue ;  the  amount  of  hemorrhage  it 
often  causes,  and  its  severe  effects  upon  the  nervous  system.  But  the 
most  important  objection  to  it,  perhaps,  is  the  shrinkage  and  conden- 
sation it  brings  about  in  the  cervix. 

After  it  has  been  used  with  any  thoroughness  for  a  long  time  the 
cervix,  and  sometimes  the  uterus,  is  diminished  in  size  and  indurated. 
Although  hemorrhage  is  a  common  symptom  immediately  following 
the  application,  it  is  not  unusual  that  the  protracted  use  of  it  leads  to 
suppression,  more  or  less  completely,  of  the  menstrual  flow.  It  must 
be  admitted,  however,  that  these  objections  apply  more  to  what,  in 
our  present  knowledge  of  its  effects,  we  would  consider  the  injudicious 
application  of  it  in  solid  form.  In  solution  it  may  be  made  to  pro- 
duce an  alterative  influence  that  is  difficult  to  effect  with  any  other 
remedy. 

A  50  per  cent,  solution,  applied  with  the  swab,  is  not  a  caustic,  and 
is  not  amenable  to  the  objections  just  above  mentioned,  and  intended 
to  apply  to  the  solid  form. 

Whatever  the  application  may  be,  it  should  not  be  repeated  if  fol- 
lowed by  evidences  of  serious  irritation,  as  pain,  lasting  for  over  an 
hour;  tenderness  in  the  iliac  or  hypogastric  region;  chilliness  or 
febrile  excitement. 

When  an  application  is  made  from  which  we  expect  any  consider- 
able pain  or  reaction,  the  patient  should  lie  down  and  remain  quiet 
until  all  sense  of  inconvenience  has  passed  away. 

As  before  remarked,  we  may  frequently  secure  immunity  from 
suffering  by  following  the  application  with  a  tampon  of  glycerin 
cotton. 

Treatment  of  Endometritis. 

When  the  disease  is  confined  to  the  cervical  cavity  the  simpler 
forms  can  be  cured  by  the  same  kind  of  application  made  use  of  in 
the  treatment  of  ordinary  inflammation  and  abrasion  of  the  cervix. 
To  make  these  efficacious  it  will  be  necessary  to  remove  the  mucus 
from  the  cervical  cavity  by  wiping  it  away  with  cotton,  when  that  is 
practicable,  and,  when  not,  it  may  be  removed  by  a  syringe. 

With  the  ordinary  flexible  applicator,  wrapped  with  cotton,  the 


430  LOCAL   TREATMENT. 

remedy  is  passed  into  the  cervical  cavity  up  to  the  internal  os  uteri. 
The  same  precaution  should  be  observed  in  other  cases  in  which  the 
application  is  made. 

The  treatment  of  these  simple  cases  is  really  not  more  difficult  than 
when  the  disease  is  on  the  outer  cervical  mucous  membrane.  And 
as  the  external  cervical  inflammation,  with  erosions,  coexists  with 
the  endocervical,  they  should  both  be  treated  at  the  same  time,  by 
first  making  the  application  externally,  and  then  passing  it  into  the 
cervical  cavity. 

We  sometimes  meet  with  an  obstinate  yet  uncomplicated  form  of 
endocervicitis,  or  cervical  catarrh,  that  resists  all  of  the  usual  remedies. 

The  cervix  is  filled  with  an  extremely  tenacious  mucus  that  is  re- 
moved with  great  difficulty,  the  cavity  of  the  cervix  is  enlarged,  and 
when  the  mucous  membrane  is  exposed  may  be  seen  to  be  very  rough, 
granulated,  and  scarlet  red.  The  granular  eminences  are  the  enlarged 
muciparous  glands,  the  glands  of  Naboth.  Dr.  Sims*  reports  cases  of 
this  kind  cured  by  thoroughly  scraping  the  cervical  cavity  with  a 
sharp  curette,  and  afterwards  touching  the  surface  lightly  with  the 
actual  cautery.  Dr.  Isaac  E.  Taylor,  of  New  York,  says  he  has  re- 
sorted to  this  treatment  with  great  success. 

When  the  inflammation  extends  to  the  cavity  of  the  body  of  the 
uterus  the  treatment  is  more  difficult  of  accomplishment,  attended 
with  less  satisfactory  results,  and  sometimes  followed  by  severe  symp- 
toms. 

When  it  is  uncomplicated,  and  the  cervical  canal  at  both  extremi- 
ties is  patent,  the  treatment  is  generally  simple  and  efficacious.  The 
applications  adapted  to  this  form  of  disease  are  the  same  as  for  endo- 
cervicitis and  are  made  in  the  same  way.  The  applicator  charged 
with  the  remedy  is  carried  to  the  fundus,  and  by  a  gentle  rotary 
movement  made  to  touch  the  whole  endometrium. 

Ordinarily  these  applications  are  not  very  painful.  This  form  of 
endometritis,  when  the  cervical  canal  is  sufficiently  open,  may  also  be 
successfully  treated  by  the  dull-wire  curette.  This  instrument  may 
generally  be  passed  with  great  ease,  and,  after  it  is  introduced,  it  is 
gently  passed  over  the  whole  surface  of  the  cavity.  This  can  be  re- 
peated once  a  week  if  necessary. 

I  could  report  several  cases  where  the  curette  used  in  this  way  has 
done  more  good  tha,n  any  other  remedy  used,  and  apparently  com- 
pleted the  cure. 

The  curette  in  these  cases  is  used,  not  for  the  purpose  of  cutting 
away  any  portion  of  the  living  membrane,  nor  for  removing  growths 
or  granulations,  but  for  the  purpose  of  stimulating  the  circulation  in 
the  mucous  membrane. 

*  Transactions  of  the  American  Cxynecological  Society,  1879. 


TREATMENT    OP    ENDOMETRITIS. 


431 


When  endometritis  is  complicated,  the  treatment  will  of  course  be 
very  much  modified  by  the  complicating  circumstances.  Stenosis 
from  contraction  is  a  very  inconvenient  complication,  because  it  must 
be  overcome  temporarily  at  least  before  our  applications  can  be  made 
complete. 

In  this  form  I  have  frequently  succeeded  by  using  the  slippery-elm 
tent.     The  tent  can  be  made  to  overcome  the  stenosis  and  at  the  same 

Fig.  206. 


Slippery-elm  Tent. 


time  exert  a  salutary  influence  by  pressure  upon  the  mucous  mem- 
brane of  the  uterine  cavity,  and  thus  suffice  to  effect  a  cure. 

The  slippery-elm  tent  is  made  about  one  inch  and  a  half,  or  one 
and  three-fourths  long,  and  the  sixth  of  an  inch  in  diameter  at  the 
large  extremity,  and  small  enough  at  the  other  to  pass  through  the 


432 


LOCAL,   TREATMENT. 


narrowest  place.  Every  tent  should  be  securely  fixed  by  threads  so 
that  it  cannot  be  lost  in  the  cavity,  and  may  be  easily  removed. 

When  we  use  them  we  thoroughly  moisten  them  for  two-thirds  the 
distance  from  the  extremity  to  be  introduced.  This  moistening  may 
be  done  in  a  moment  by  dipping  them  into  water  and  then  pinching 
and  bending  them. 

The  part  thus  moistened  should  be  soft  enough  to  bend  in  any  di- 
rection with  very  slight  force.  When  the  cervix  is  exposed  we  take 
the  dry  end  of  the  tent  in  our  dressing  forceps  and  pass  the  moistened 
end  into  the  uterus.  The  pliability  of  the  tent  enables  us  to  pass  it 
easily  into  the  most  tortuous  canal.    After  having  passed  one,  if  we 


Fig.  207. 


Slippery-elm  Tent  introduced. 


are  not  satisfied,  we  may  introduce  one  by  the  side  of  it,  and  then 
two,  three,  four,  or  a  dozen,  until  we  have  dilated  the  canal  suffi- 
ciently. These  may  be  allowed  to  remain  several  hours  if  necessary, 
to  cause  further  dilatation.  But  often  they  may  be  removed  at  once, 
and  the  cervix  Avill  be  large  enough  to  receive  an  application.  I 
know,  however,  from  frequent  trial  that  no  other  application  is  neces- 
sary to  cure  many  cases  of  endometritis. 

When  I  introduce  one  or  two  tents,  in  cases  where  stenosis  com- 
plicates endometritis,  I  instruct  the  patient  to  remove  the  tent  by 


TEEATMENT  OF  ENDOMETRITIS. 


433 


drawing  upon  the  thread  whenever  it  gives  her  decided  pain,  and  to 
not  let  it  remain  more  than  twelve  hom^s  if  it  does  not  give  her  pain. 
This  is  by  far  the  most  comfortable  way  of  dilating,  and  according 
to  my  observation,  the  most  effective.  The  slippery  elm  has  the  ad- 
vantage of  being  inexpensive  and  easily  procured.  In  ten  minutes 
the  practitioner  can  make  a  dozen  Avith  his  pocket-knife,  out  of  the 
dry  bark  found  in  any  drug  store.  When  used  in  this  way,  and  for 
this  purpose,  the  dilatation  is  very  moderate,  but  by  repeating  it  be- 
comes permanent  more  readily  than  by  the  use  of  any  other  means. 
I  can  say  further  that  I  have  had  no  bad  results  from  slippery-elm 
tents  when  used  in  this  way,  and  in  those  exceptional  cases  alone 
where  a  mere  touch  of  the  probe  is  painful  do  I  apprehend  the  pos- 
sibility of  harm.  It  is  the  safest  means  to  dilate  the  cervix  now  in 
use,  and  when  several  are  introduced  by  the  side  of  each  other  they 
may  be  made  to  dilate  the  cervical  cavity  in  a  few  minutes. 

Fig.  208. 


The  Uterus  In  a  state  of  Anteflexion,  with  the  Slippery-ehn  Bougie  introduced  into  it.. 

This  tent  also  may  be  made  to  shield  the  cervix  from  the  effects  of 
the  pressure  of  the  more  energetic  dilators.  If  we  wish  to  dilate  the 
cervix  largely  we  may  pass  a  sea- tangle  or  sponge  tent,  and  then  fill 
the  cervical  cavity  around  it  by  slippery-elm  tents. 

As  the  sea- tangle  or  sponge  expands,  the  elm  tents  shield  the  deli- 
cate mucous  membrane  from  contact  with  the  hard  tent,  and  when  the 
time  comes  to  remove  it  there  will  be  no  difficulty  in  getting  it  away. 
Complicating  misplacements,  especially  retroversions,  should  be  cor- 
rected as  an  indispensable  item  of  treatment.  After  the  correction  is 
made  the  treatment  will  not  differ  in  any  respect  from  the  uncompli- 
cated case. 

Flexions  are  more  embarrassing  complications  than  displacements, 

28 


434  LOCAL    TREATMENT. 

because  the  point  of  greatest  flexion  is  stenotic.  Sometimes  the  ste- 
nosis is  so  great  that  it  is  difficult  to  pass  a  small  sound.  (Fig.  208.) 
The  correction  of  the  complication  and  the  treatment  of  the  inflam- 
mation may  both  be  accomplished  at  the  same  time.  These  are  the 
cases  in  which  the  slippery-elm  tent  will  be  of  the  greatest  service. 
They  are  often  attended  with  the  dysmenorrhoea  of  obstruction.  We 
can  dilate  and,  to  a  certain  extent,  correct  the  flexion  every  time  we 
make  an  application,  by  using  one  or  two  elm  tents  before  introducing 
the  application.  But  generally  the  tents,  if  allowed  to  remain  in  the 
cavity,  as  directed  in  the  treatment  of  stenosis  just  described,  will  ex- 
ert a  salutary  effect  by  pressure. 

When  the  practitioner  finds  that  a  pessary  can  be  used  to  advantage, 
it  may  be  employed  at  the  same  time  with  the  other  treatment. 

When  complicated  by  menorrhagia  both  diseases  may  generally  be 
cured  by  the  curette  used  as  above  directed. 

I  have  said  nothing  about  intrauterine  injections  as  a  means  of  cur- 
ing endometritis.  The  subject  has  been  very  thoroughly  discussed  by 
the  members  of  the  profession,  and  few  prominent  gynecologists  resort 
to  this  means  in  any  form  or  at  any  time,  except  in  the  puerperal  con- 
dition of  the  organ.  For  my  own  part,  I  have  never  injected  the  uterus 
for  endometritis,  and  I  do  not  hesitate  to  condemn  it  in  such  cases  as 
dangerous,  and  yet  there  are  those  for  whose  opinions  I  have  the  high- 
est respect,  who  advise  and  employ  injections,  and  speak  of  them  as 
the  most  efficacious  of  all  methods  of  applying  medicines  to  the  in- 
terior of  the  uterus. 

Professor  James  P.  White,*  of  Buffalo,  has  invented  a  pipette  of 
glass,  bent  to  the  shape  of  the  uterus,  with  a  bulb  of  india-rubber  at 
the  external  end.  He  dips  the  end  of  the  tube,  which  is  very  minute 
in  size,  into  the  fluid  he  desires  to  use,  and  then  passes  it  through 
a  speculum  into  the  uterine  cavity,  and  presses  out  in  drops,  or  as 
much  as  he  desires  to  leave  there.  The  small  quantity  thus  intro- 
duced he  claims  cannot,  and  does  not,  give  rise  to  any  grave  symp- 
toms. 

In  discussing  the  paper  thus  referred  to.  Dr.  Munde,  of  New  York, 
said  :  That  he  applies  fluids  to  the  cavity  of  the  uterus  through  a  very 
small  flexible  tube  invented  by  Dr.  Buttles,  of  New  York.  He  thinks, 
cautiously  done,  this  is  a  safe  and  efficacious  way  of  treating  the  in- 
terior of  the  uterus.  This  method  of  using  fluids  in  the  cavity  of  the 
uterus  can  hardly  be  classed  among  injections,  as  the  term  has  been 
heretofore  understood. 

*  Paper  read  before  the  American  Gynecological  Society,  1879. 


CHAPTER    XXIII. 

LACEEATIONS  OF  THE  CERVIX  UTERI. 

The  consequences  of  this  accident  are  so  serious,  and  its  occurrence 
so  frequent,  that  it  demands  a  prominent  place  in  every  text^book  on 
gynecology. 

While  many  observers  had  noted  the  presence  of  lacerations  of  the 
cervix  uteri,  their  importance  until  lately  has  been  underrated ;  they 
were  thought,  in  fact,  to  give  rise  to  no  appreciable  effects. 

This  view  was  encouraged  by  the  fact  that  a  proper  treatment  of 
their  consequences  generally  resulted  in  a  temporary  and  sometimes 
permanent  removal  of  the  symptoms. 

Until  Dr.  Emmet  made  his  remarkable  researches  upon  the  sub- 
ject, laceration  of  the  cervix  j^assed  for  one  of  the  forms  of  ulceration 
and  was  described  as  ulceration  of  the  cervix  uteri.  Now,  however, 
owing  to  the  enthusiasm  of  the  discoverer,  many  of  his  students  have 
gone  to  what  I  consider  an  unjustifiable  extreme  in  the  other  direc- 
tion, expressing  their  opinions  that,  instead  of  everything  being  called 
ulceration,  the  proper  term  is  laceration  of  the  cervix. 

To  Dr.  Emmet  belongs  the  credit  of  first  appreciating  the  impor- 
tance and  appropriately  treating  this  accident. 

It  very  seldom  occurs  to  any  man  to  have  the  opportunity  of  giving 
to  the  profession  so  complete  a  description  of  an  abnormal  condition, 
and  to  perfect  the  process  of  cure,  so  that  there  is  left  to  others  but  little 
room  for  improvement.     Yet  this  is  the  good  fortune  of  Dr.  Emmet. 

Causes. 

Laceration  of  the  cervix  occurs  during  labor  or  expulsion  of  the 
contents  of  the  uterus  in  abortion.  Sudden  expulsion  of  the  head  in 
cases  where  the  cervix  is  not  dilated  sufficiently  may  eventuate  in  its 
rupture. 

It  would  be  foreign  to  my  purpose  at  present  to  discuss  the  various 
causes  of  the  rigidity  which  prevents  the  ready  dilatation  of  the  cer- 
vix. They  certainly  are  numerous  and  of  frequent  occurrence.  Nor 
do  I  consider  it  necessary  to  criticise  the  early  and  frequent  use  of  the 
forceps  practiced  by  the  accoucheur  of  the  present  day.  The  time  has 
not  yet  come  when  the  facts  are  at  hand  to  justify  such  criticism.  It 
is  in  order,  however,  to  inform  the  obstetrician  that  his  patients  come 
to  the  gynecologist  with  laceration  of  the  cervix  in  great  numbers. 
Dr.  Emmet  finds  laceration  in  about  16  per  cent,  of  the  cases  coming 


436  L,ACEEATIONS   OF   THE   CEEVIX   UTERI. 

to  him  for  treatment  on  account  of  uterine  disease.  Dr.  Munde  puts 
them  down  at  about  17  per  cent.,  Dr.  Montrose  A.  Fallen  at  40  per 
cent.,  and  Dr.  Goodell  says  one  in  every  six  of  his  dispensary  patients 
has  laceration  of  the  cervix.  My  own  observation  confirms  the 
opinion  that  these  lacerations  are  of  very  frequent  occurrence.  Ob- 
serving the  difference  in  virgin,  as  compared  to  the  parous  uteri,  one 
must  conclude  that  slight  laceration  from  labor  was  the  rule. 

Can  extensive  laceration  of  the  cervix  always  be  avoided  ?  This 
question  brings  to  mind  the  frequency  with  which  the  perineum  is 
torn  under  the  management  of  the  best  practitioners,  and  the  univer- 
sality with  which  slight  laceration  of  that  body  takes  place  in 
primiparous  women. 

The  Degree,  Locality,  and  Direction. 

The  degree  of  laceration  varies  from  the  slight,  a,lmost  inappreciable 
rupture  to  the  splitting  of  the  cervix  into  and  above  the  vaginal  junc- 
tion. It  may  be  confined  to  one  side,  while  the  other  retains  its 
integrity,  or  both  sides  may  be  torn,  one  slightly  and  the  other  largely, 
or  both  to  their  utmost  extent. 

The  locality  of  the  laceration  is  much  more  frequent  in  a  line  cor- 
responding to  the  junction  of  the  anterior  and  posterior  halves  of  the 
cervix,  but  sometimes  the  anterior  or  posterior  lip  of  the  uterus  is 
torn  in  the  centre  in  the  various  degrees  above  mentioned ;  in  others 
both  the  anterior  and  posterior  lips  are  thus  lacerated.  In  rare  in- 
stances we  find  the  two  lateral  and  the  two  central  lesions  in  the  same 
cases,  making  the  cervix  project  into  the  vagina  with  four  points.  I 
have  seen  one  case  where  the  anterior  lip  was  split  up  to  the  vaginal 
junction,  and  then  torn  across  to  the  left  side,  the  portion  torn  hang- 
ing down  into  the  vagina. 

Dr.  Emmet  thinks  that  the  anterior  and  posterior  labia  are  fre- 
quently torn,  but  from  the  direction  of  the  vaginal  pressure  they 
generally  heal  up,  and  consequently  do  not  often  come  under  our 
observation.  It  is  not  unlikely,  as  he  observes,  that  many  lateral,  as 
well  as  central,  lacerations  close  up  during  the  term  of  lying  in,  and 
therefore  never  give  rise  to  any  inconvenience. 

Effects  of  the  Laceration. 

If  we  were  guided  by  what  we  know  of  traumatic  lesions  elsewhere, 
as  well  as  what  we  find  in  the  cervix  itself,  we  would,  a  priori,  infer 
that  inflammation  was  an  early  consequence  of  the  accident. 

The  torn  edges,  much  more  frequently  than  otherwise,  become 
covered  with  cicatricial  tissue,  the  result  of  inflammatory  exudation, 
and  a  large  amount  of  this  cicatricial  deposit  is  occasionally  found  in 
the  angle  of  the  laceration.     Sometimes  this  last  point  of  deposit 


COMPLICATIONS.  437 

presents  a  tough,  hard  node,  that  must  be  removed  with  great  care 
to  secure  perfect  results. 

This  is  not  all  the  effects  of  the  inflammatory  action.  Sometimes 
a  fibrino-plastic  exudation  in  the  connective  tissue  of  the  two  cervical 
flajjs  takes  place,  and  they  become  large,  dense,  and  hard. 

The  surgeon  will  often  find  the  cervix  indurated  so  greatly  that  it 
resists  the  instruments,  especially  the  passage  of  the  needles;  and  he 
will  find,  as  a  rule,  the  more  extensive  the  laceration,  the  greater  will 
be  this  particular  change,  showing  that  they  are  all  the  seat  of  the 
most  intense  inflammatory  action,  and  the  converse. 

Another  effect  of  the  laceration  on  the  parts  is,  at  first,  an  inflam- 
matory action  in  the  mucous  membrane  of  the  cervical  cavity. 
Fibrino-plastic  deposits  occur  in  the  dee^Der  portions  of  the  mem- 
brane, which  becomes  turgid  and  redundant;  its  epithelium  is  shed, 
and  it  presents  a  scarlet,  rough  surface.  Sometimes  the  redundancy 
of  the  membrane  is  so  great  that  it  rolls  out  and  forms  a  mass,  fun- 
giform in  appearance. 

As  another  consequence  of  this  fibrino-plastic  exudation,  the  mouths 
of  many  of  the  ducts  leading  from  the  glands  of  Naboth  are  closed, 
and  the  mucus  of  the  glands  is  confined  within  their  cystic  cavities, 
or  the  whole  gland  is  surrounded  by  the  exudation  and  becomes  in- 
volved in  the  hardened  mass.  Thus,  in  different  cases,  we  find  the 
glands  presenting  the  appearance  of  translucent  blebs  or  shot-like 
granulations. 

Effects  on  the  Body  of  the  Uterus. 

The  inflammatory  process  going  on  in  the  cervix,  resulting  from 
lacerations,  arrests  involution,  and  the  uterus  remains  large  and  vas- 
cular ;  in  other  words,  in  a  state  of  subinvolution  until  the  chronic 
inflammation  is  removed  by  proper  treatment  of  the  mucous  mem- 
brane and  submucous  tissue,  and  the  laceration  closed  by  hystero- 
trachelorraphy. 

That  lacerations  which  do  not  cause  and  maintain  this  uterine 
hypertemia  are  innocent  of  general  disturbances,  is  admitted  by  Dr. 
Emmet,  as  I  have  shown  elsewhere  by  quotations  from  his  work.* 

Complications. 

Other  embarrassing  complications  of  laceration  of  the  cervix  are 
displacements,  prolapse,  and  retroflexions,  and  lacerations  of  the  peri- 
neum and  vagina,  and  cellulitis  and  local  peritonitis.  These  com- 
plications increase  the  hypersemia  of  the  uterus, — retroflexion,  by 
constriction  of  the  cervix  and  consequent  turgescence  of  that  portion 
of  the  uterus  with  this ;  and  prolapse,  by  altering  the  direction  of 

*  Article  on  Subinvolution. 


438  liAciERATiojsrs  of  the  cervix  uteri. 

the  veins  which  carry  the  blood  from  the  uterus,  augmenting  the 
previously  existing  hypersemia  of  that  organ.  The  uterus  is  thereby 
increased  in  weight,  fibrino-plastic  changes  produced  in  its  substance, 
and  the  nutrition  of  the  mucous  membrane  of  its  cavity  disturbed  in 
a  marked  degree. 

Symptoms. 

The  general  symptoms  following  laceration  of  the  cervix  are  not 
distinctive.  That  lesion  produces,  through  its  effects  upon  the  body 
and  cervix  uteri,  the  symptoms  given  in  detail  elsewhere,  under  the 
head  of  Hysteropathy,  and  consequently  need  not  be  repeated  here. 

Diagnosis. 

This  cannot  be  made  out  by  subjective  symptoms  alone,  and  we 
must  depend  upon  a  thorough  examination  of  the  j^arts  by  the  touch 
and  use  of  instruments.  By  careful  examination  with  the  finger  the 
notch  in  the  side,  when  large,  will  be  easily  detected.  The  finger 
should  pass  along  the  vaginal  wall  to  its  junction  with  the  cervix, 
and  keeping  it  in  the  cul-de-sac,  passed  all  around  so  as  to  encircle 
the  neck. 

In  most  instances,  as  the  finger  passes  over  the  side,  we  will  rec- 
ognize the  fact  that  at  that  point  the  neck  does  not  extend  below  the 
vaginal  junction.  The  finger  will  sink  into  a  depression  between 
the  labia. 

When  the  finger  is  educated  in  the  vaginal  touch,  the  lesion  will  be 
easily  recognized. 

The  sound  will  generally  pass  deeper  into  the  body  of  the  uterus 
than  it  will  in  the  normal  state  of  that  organ,  because  the  uterus  is 
in  a  state  of  subinvolution. 

When  well  exposed  by  the  speculum,  the  cervix  will  generally  be 
found  covered  by  a  muco-purulent  fluid,  enlarged,  the  labia  turned 
out,  the  exposed  cavity  of  the  neck  intensely  red,  and  the  surface 
roughened  in  consequence  of  the  loss  of  epithelium,  and  an  enlarge- 
ment of  the  papillae  and  muciparous  glands.  The  infallible  test, 
however,  is  to  seize  the  extremities  of  both  labia  with  tenacula  and 
draw  them  down  together,  somewhat  forcibly.  If  the  cer^dx  has 
been  torn  on  the  side,  the  notch  will  be  plainly  seen.  If  there  is  no 
laceration,  the  cervix  will  be  truncated  instead  of  bifid,  and  the  points 
of  the  tips  can  be  drawn  down  only  a  trifling  distance  below  their 
lateral  junction. 

Treatment. 

The  treatment  may  be  preventive,  preparatory,  and  operative. 
The  prevention  of  laceration  of  the  cervix  does  not  usually  come 
within  the  province  of  the  gynecologist.     The  obstetrician  has  charge 


PEEPAEATORY  TEEATMENT.  439 

of  the  patient  at  the  time  of  the  accident,  and  upon  his  skill  will  de- 
pend such  immunity  as  can  be  secured  by  science.  The  probability 
is  that  it  cannot  be  prevented  in  most  instances  in  which  it  occurs, 
no  more  than  laceration  of  the  perineum  can  always  be  prevented. 
I  can  easily  see  how  an  early  rupture  of  the  membranes,  a  too  early 
use  of  the  forceps,  or  an  ill-advised  administration  of  ergot  would 
favor  laceration  of  the  cervix. 

Now  that  their  attention  is  called  to  the  subject,  obstetricians  will 
no  doubt  soon  be  able  to  furnish  the  facts  upon  which  may  be  based 
a  judicious  preventive  treatment;  at  present  it  must  be  founded  upon 
a  rational  view  of  the  processes  of  labor. 

Preparatory  Treatment. 

The  treatment  preparatory  to  an  operation  has  been  as  fully  devel- 
oped by  Dr.  Emmet  as  any  part  of  the  subject,  and  my  experience 
corroborates  the  correctness  of  his  teachings. 

The  object  of  the  preparatory  treatment  is  to  bring  about  a  plastic 
condition  of  the  parts  to  be  united.  This  is  accomplished  by  correct- 
ing any  deviation  from  the  normal  state  of  general  health  by  tonics, 
nutritious  diet,  exercise  in  the  open  air,  promoting  a  soluble  condition 
of  the  bowels  with  appropriate  laxatives,  etc. 

A  robust  state  of  the  general  health  is  an  all-important  part  of  the 
preparation  in  this  as  in  all  plastic  operations. 

The  local  preparatory  treatment  consists,  first,  in  placing  the  uterus 
in  such  position  as  is  necessary  to  secure  the  greatest  possible  freedom 
of  circulation,  for  the  purpose  of  reducing  the  general  hyperemia  of 
that  organ ;  second,  making  use  of  such  applications  as  will  reduce 
the  hypersemia  of  the  uterus  and  cervix;  and,- third,  where  there  is 
induration  from  fibrino-plastic  exudation  in  the  connective  tissue  of 
the  cervical  flaps  to  as  far  as  possible  dissolve  it  out  and  bring  about 
a  normal  condition  of  the  structure. 

The  first  indication  is  Diet  by  a  judicious  use  of  pessaries  of  cotton, 
lint,  and  the  closed-lever  instrument.*  The  second,  calls  for  the  use 
of  glycerin,  cotton  tampons,  local  bloodletting  by  puncture  with 
Buttle's  lancet-shaped  knife,  or  other  instrument  which  will  answer 
the  same  purpose,  and  large  hot- water  injections.  An  employment 
of  these  means  perseveringly  for  a  sufiicient  length  of  time  will  be 
pretty  sure  to  effect  this  object.  The  third  will  generally  require 
more  time,  and  is  of  equal  importance  with  the  other  two.  The  ap- 
plications for  this  purpose  consist  in  remedies  that  will  stimulate  the 
absorbents  to  the  removal  of  the  indurating  substance.  Dr.  Emmet- 
relies  to  a  great  extent  upon  Churchill's  tincture  of  iodine  for  this. 

*  See  Displacement, 


'AO 


J.ACERATIOXS    OF    THE    CERVIX   UTEEI. 


purpose.  He  applies  it  freely  to  the  whole  of  the  denuded  mucous 
membrane  about  twice  a  week,  followed  by  glycerin  dressings.  It  is 
doubtless  an  excellent  application.  Occasional  moderate  dilatation 
by  Peaslee's  or  Hanks's  dilators,  often  has  a  beneficial  effect  upon  the 
cicatrized  tissues  high  up  in  the  cervix,  and  improves  the  circulation. 

When  the  gland  cysts  are  large  and  numerous,  Emmet  pricks  them 
with  the  lancet-shajDed  knife  to  void  their  contents  and  to  deplete  them 
of  blood. 

In  many  cases  of  long  standing,  and  where  the  pathological  changes 
are  greatest,  the  prejoaratory  treatment  will  require  to  be  employed 
for  several  months  to  secure  the  best  results.  In  others  of  recent 
standing,  and  where  the  changes  consist  mostly  of  hypersemia,  a  few 
weeks  will  suffice. 

The  Operation. 

To  Dr.  Dudley,  of  this  cit}",  is  conceded  the  honor  of  first  giving 
this  operation  an  appropriate  name,  "trachelorraphy."  Two  or  three 
days  after  the  menses  cease  to  flow  is  the  best  time  to  operate. 

Fig.  209. 


The  Cervix  with  the  Threads  passed. 


The  day  before  the  operation  it  is  a  common  practice,  and  I  think  a 
good  one,  to  move  the  bowels  pretty  thoroughly  by  giving  a  laxative. 


THE    OPERATION. 


441 


At  the  time  of  the  operation  I  usually  give  the  patient  ether.  This, 
however,  is  not  absolutely  necessary,  especially  in  cases  of  moderate 
extent,  as  the  operation  is  not  very  painful. 

The  patient  is  placed  in  Sims's  or  Simon's  position,  and  the  vagina 
dilated  as  largely  as  necessary  to  bring  the  cervix  into  view.     The 


Fig.  210. 


neck  is  then  seized  with  a  vulsellum  forceps,  and  drawn  down  until 
the  lips  can  be  transfixed  from  before  backward  by  a  strong  needle 
armed  with  a  double  thread. 

The  threads  are  drawn  through  enough  to  form  two  loops,  each 
through  one  of  the  labia,  of  sufficient  length  to  pass  several  inches 


Fig.  211. 


Byford's  Uterine  Scissors. 


out  of  the  vaginal  orifice.  With,  these  loops  of  thread  the  cervix  can 
be  very  completely  fixed,  and  its  position  varied,  as  the  convenience 
of  the  operator  may  require.  The  loops  of  thread  may  be  held  up  by 
an  assistant,  subject  to  the  direction  of  the  surgeon.  A  small  curved 
tenaculum  forceps  may  be  used  for  holding  the  cervix  in  position,  or 
a  strong  double  tenaculum. 


442  LACEEATIOXS    OF    THE    CERVIX    UTERI. 

When  thus  prepared  the  oiDerator  seizes  the  edge  of  the  laceration 
with  a  tenaculum,  and  with  scissors  j^ares  off  all  the  cicatricial  mem- 
brane. The  denudation  should  he  carried  up  into  the  angle  between 
the  cervical  flaps  and  the  wedge  of  cicatricial  deposit  thoroughl}^  re- 
moved. In  doing  this  care  should  be  taken  to  cut  off  any  irregularity 
of  surface  on  the  edge  of  the  laceration,  so  that  the  edges  of  the  two 
sides  may  be  brought  into  smooth  coaptation.  After  the  denudation 
is  perfected,  and  the  hemorrhage  ceases,  the  stitches  may  be  intro- 
duced. Beginning  an  eighth  of  an  inch  from  the  incision  on  the  outer 
surface  of  the  flap,  the  needle  is  passed  perj)endicularly  through  to  a 
point  that  will  include  the  same  distance  of  the  endo-cervical  mem- 
brane. To  the  thread  in  the  needle  should  be  attached  silver  wire 
eight  or  ten  inches  long,  drawn  through  and  held  by  an  assistant, 
until  all  of  the  wires  are  placed  as  in  Fig.  212.  Before  twisting  the 
wire  the  edges  of  the  wound  should  be  wiped  clean  of  every  small 
coagulum.  If  this  precaution  is  not  taken  a  clot  of  blood  ma}^  be 
included  between  the  united  edges  and  prevent  comj^lete  union.  The 
wires  may  then  be  twisted  evenly,  as  represented  in  Fig.  213.  Pre- 
pared catgut,  silkworm  gut,  and  silk  thread  are  equally  as  good  as  the 
silver  wire.  I  now  always  use  the  silk  thread.  After  the  operation 
the  vagina  should  be  thoroughly  cleansed  and  the  patient  j)ut  to  bed. 

As  the  reader  will  see,  this  operation  is  a  simple  one,  under  favor- 
able circumstances,  i.  e.,  when  the  laceration  is  lateral,  and  does  not 
extend  above  the  vaginal  junction.  When  it  is  stellate,  or  there  is 
much  loss  of  tissue,  the  ingenuity  of  the  surgeon  will  be  severely 
taxed. 

I  am  not  informed  as  to  the  average  number  of  successes  in  the 
operation  of  trachelorraphy,  but  I  know  that  failures  are  not  infi'e- 
quent,  and  it  may  be  well  to  consider  what  are  the  reasons  of  failure. 

Among  these  reasons  is  an  imperfect  performance  of  the  operation, 
but  chief  among  them  is  imperfect  jDreparation. 

The  after-treatment  is  of  great  importance,  especially  for  the  first 
few  da3^s.  The  patient  must  remain  very  quiet  and  avoid  all  causes 
of  vascular  and  nervous  derangements.  After  this  time  there  can  be 
more  freedom  of  motion.  It  is  desirable  that  the  bowels  be  not  moved 
before  the  end  of  this  time,  when  a  laxative  may  be  given,  and  means 
taken  thenceforward  to  keep  them  in  a  soluble  condition.  If  we  do 
not  conclude  to  prevent  the  evacuation  of  the  bowels,  we  should  ad- 
minister diet  and  saline  laxatives  to  soften  the  fseces. 

It  has  been  usual  to  draw  off  the  urine  for  the  first  four  or  five 
days,  but  this  is  not  essential,  as  it  is  only  necessary  to  avoid  straining. 

The  diet  must  be  light,  and  for  the  most  part  liquid,  for  the  first 
few  days. 

The  vagina  should  be  kept  clean  by  warm-water  injections  two  or 
three  times  a  day  from  the  beginning  to  the  end  of  the  after-treat- 


THE    OPERATION. 


443 


ment.  I  have  been  in  the  habit  of  removing  the  sutures  about  the 
tenth  day,  but  in  the  majority  of  cases  they  might  be  taken  out  on 
the  seventh  or  eighth  clay. 

Fig.  212. 


The  Mode  of  Passing  the  Sutures. 
Fig.  213. 


The  Sutures  Properly  Placed  and  Twisted. 


CHAPTEK    XXIV. 

OCCASIONAL  UNTOAVAED  EFFECTS  OF  UTERINE  MANIPULATIONS 
AND  OPERATIONS. 

For  the  purpose  of  making  the  student  understand  the  necessity  of 
great  caution  and  gentleness  in  examinations  and  operations  upon  the 
uterus,  I  subjoin  a  summary  of  the  researches  of  Dr.  George  J.  Engle- 
man,  of  St.  Louis,  on  the  subject.* 

Many  of  the  cases  mentioned  by  Dr.  Engleman  occurred  in  the 
hands  of  the  most  accomplished  practitioners  in  different  parts  of  the 
world. 

A  simple  digital  examination  of  the  unimpregnated  uterus,  in  the 
hands  of  Nelaton,  was  followed  by  fatal  peritonitis. 

Several  cases  of  death  from  peritonitis  were  the  result  of  the  use  of 
the  uterine  sound ;  some  because  the  sound  perforated  the  uterine 
tissues  on  account  of  fatty  degeneration  rendering  them  soft  and  j)er- 
meable  ;  others  without  any  apparent  reason. 

There  are  also  cases  in  which  untoward  results  followed  the  use  of 
vaginal  injections  of  warm  water. 

A  number  of  deaths  are  recorded  in  which  peritonitis  was  caused 
by  the  use  of  sponge  tents.  One  case  is  mentioned  of  severe  perito- 
nitis from  replacing  the  uterus  by  means  of  the  sound.  There  is 
always  more  or  less  risk  in  this  operation.  Dr.  J.  M.  Allen  gives  a 
case  in  which  death  was  caused  by  the  application  of  tincture  of 
iodine  to  the  cervix. 

Cellulitis  has  followed  the  application  of  various  substances  to  the 
cervical  and  uterine  canal. 

The  danger  of  injections  into  the  uterine  cavity  is  shown  by  allu- 
sion to  several  cases  of  death  in  the  hands  of  skilful  gynecologists. 
The  most  trivial  operations  on  the  uterus  or  other  organs  in  the  pehdc 
cavity  are  sometimes  followed  by  fatal  results.  Even  scarification  of 
the  cervix  has  been  the  cause  of  fatal  peritonitis. 

I  have  known  of  two  cases  of  death  follow  incision  of  the  cervical 
canal,  and  several  others  are  mentioned  in  Dr.  Engieman's  pajier. 
Operations  for  lacerations  of  the  cervix  have  been  followed  by  death 
in  several  instances.  The  most  careful  removal  of  small  polypi  may 
be  the  cause  of  fatal  peritonitis. 

Perineorrhaphy  has,  in  a  number  of  instances,  been   followed  by 


*  Paper  read  before  the  Missouri  Jledical  Society,  and  publislied  in  September  No., 
1880,  American  Practitioner. 


UTERINE    MANIPULATIONS    AND    OPEEATIONS.  445 

similar  consequences.  Stem  pessaries,  when  incautiously  used,  are 
very  dangerous  instruments. 

It  therefore  appears  that  any  kind  of  manipulation  of  the  uterus  or 
its  lining  membrane  is,  under  certain  inscrutable  circumstances,  liable 
to  start  an  acute  peritonitis.  One  of  these  circumstances,  and  per- 
haps the  most  frequent  one,  is  the  existence  of  an  inappreciable  grade 
of  inflammation  in  the  cellular  or  peritoneal  structures  immediately 
surrounding  the  uterus. 

Dr.  Noeggerath  *  believes  that  latent  gonorrhoea  is  very  often  the 
character  of  this  lurking  inflammation. 

It  would  seem  that  the  use  of  sponge  tents,  intrauterine  stem  pes- 
saries, intrauterine  injections,  intrauterine  applications,  and  cutting 
operations  on  the  cervix  uteri,  were  especially  dangerous. 

We  should  exercise  great  care  in  all  our  manipulations  of  the  pelvic 
organs,  and  leave  no  precautions  known  to  gynecology  unemployed 
to  avoid  the  dangers  that  occasionally  present  themselves  when  we 
venture  upon  the  use  of  sponge  tents,  intrauterine  injections,  stem 
pessaries,  or  operate  upon  the  cervix.  Antiseptic  precautions  are  al- 
ways advisable. 

*  Gynecological  Transactions,  1876.   . 


CHAPTER     XXV. 

HYPERTROPHY  OF  THE  CERVIX. 

Hypertrophy  of  the  cervix  is  different  from  enlargement  caused 
by  fibrinous  accumulation,  and  consists  of  an  increase  in  the  proper 
tissues  of  the  organ.  It  is  a  real  hypertrophy.  Although  not  nearly 
so  frequent  as  the  enlargement  from  chronic  inflammation,  it  is  not  of 
very  rare  occurrence.  The  symptoms  do  not  differ  from  prolapse  of 
the  uterus  sufficiently  to  characterize  it.  The  patient  generally  ex- 
periences a  sense  of  bearing-down  or  weight  on  the  perineum,  pain  in 
the  sacral  region,  leucorrhoea,  sometimes  menorrhagia,  and  the  various 
sympathetic  symptoms  already  sufficiently  dwelt  upon  of  uterine  irri- 
tation. 

Diagnosis. 

Upon  examination  the  cervix  is  found  hypertrophiecl  and  enlarged. 
There  are  two  general  forms  observed  so  well  marked  as  to  entitle 
them  to  special  mention.  The  first  is  such  as  we  usually  find  in  the 
nulliparous,  an  elongation  of  the  whole  cervix,  and,  some  but  not 
generally  very  great  circumferential  increase  of  size,  and  without 
much  deviation  from  shape.  This  form  is  seen  in  Fig.  214.  The  next 
variety  is  an  elongation  and  enlargement  of  the  anterior  or  posterior 
labium,  as  represented  in  Fig.  215.  I  am  not  certain,  from  my  own 
observation,  whether  this  is  always  a  pure  hypertrophy  or  a  mixture 
of  this  process  with  fibrinous  infiltration ;  probably  the  latter. 

The  only  appropriate  treatment  is  amputation,  and  it  is  generally 
sufficient  to  remove  all  the  disagreeable  symptoms  resulting  from  it. 
The  plan  I  have  usually  pursued  in  removing  this  growth  is  by  icrase- 
ment.  The  chain  of  the  ecraseur  is  passed  around,  at  the  place  where 
the  point  marked  out  by  the  dotted  line  is  seen  in  the  figures,  and  the 
ratchet  slowly  worked  until  the  division  is  complete.  This  operation 
is  easily  performed,  and  is  perfectly  safe  when  carefully  done,  and  the 
parts  cicatrize  in  a  few  days.  An  inconvenience  mentioned  by  Dr.  J. 
Marion  Sims  is  encountered,  in  some  instances,  in  amputating  the  first 
variety,  viz.,  the  contraction  of  the  opening  of  the  cervical  cavity.  It 
is  an  inconvenience,  however,  that  is  of  no  great  importance  generally, 
and  may  be  remedied  by  making  a  small  incision  with  a  blunt-pointed 
bistoury  immediately  after  the  operation  of  amputation.     Dr.  Sims 


ELONGATION    OF   THE    SUPEA VAGINAL    CERVIX. 


447 


amputates  the  cervix  with  scissors.     He  exposes  the  organ  with  his 
speculum,  cuts  the  parts  squarely  through  at  the  dotted  lines,  and  then 


Fig.  215. 


Figures  showing  two  Varieties  of  Hypertropliic  Elongation  and  Enlargement  of  tlae  Cervix  Uteri. 
The  Dotted  Lines  show  the  Proper  Place  for  Amputation. 

draws  the  mucous  membrane  together  over  the  cut  surfaces  with  silver 
sutures.  (Figs.  217  and  218).  This  lessens  the  size  of  the  cut  surfaces, 
and  the  parts  heal  more  readily. 

Elongation  of  the  Supravaginal  Cervix. 

This  condition  of  the  cervix  so  completely  simulates  procidentia  of 
the  uterus  that  upon  a  superficial  examination  it  may  be  mistaken  for 
that  condition.  The  elongated  vaginal  cervix  with  the  vagina  are 
protruded  from  the  external  parts.  The  vaginal  walls  are  everted 
anteriorly  and  posteriorly,  forming  in  most  instances  cystocele  and 
rectocele.  Sometimes  the  protrusion  is  less  extensive,  and  the  cervix 
alone  protrudes  from  the  external  parts. 

The  diagnosis  is  made  by  introducing  the  sound.  That  instrument 
will  enter  to  a  much  greater  depth  than  when  the  uterus  is  prolapsed, 
sometimes  five  or  six  inches. 

2d.  By  placing  the  patient  in  the  knee-chest  position.  In  this  pos- 
ture the  cervix  very  readily  enters  the  pelvis  and  rises  up  to  its  normal 
position.  If  the  sound  is  now  introduced  it  will  not  enter  the  uterus 
to  so  great  a  depth. 

3d.  By  introducing  the  finger  into  the  rectum  while  the  patient  is 
standing,  we  can  feel  that  the  length  and  shape  of  the  uterus  are 
greatly  changed  from  the  normal.     The  fundus  and  body  will  be 


448  HYPERTROPHY    OF    THE    CERVIX. 

found  in  situ,  and  from  it  the  attenuated  and  elongated  supravaginal 
cervix  can  be  traced  downward  to  its  attachments  to  the  vagina. 

This  elongation  of  the  cervix  is  called  tensile  elongation  by  Dr. 
Matthews  Duncan,  and,  doubtless,  as  Dr.  Goodell*  believes,  is  the 
result  of  hypertrophy  and  stretching,  instead  of  true  hypertrophy. 
It  would  seem  at  any  rate  that  the  elasticity  of  the  cervical  tissues 
was  very  much  increased,  as  in  the  erect  posture,  with  the  slight 


Supravaginal  ElongatioD  of  the  Cervix. 

welo-ht  of  the  relaxed  vaginal  walls  and  the  bladder  and  rectum,  the 
neck  becomes  elongated,  and  when  the  patient  lies  down  retraction 
may  soon  follow. 

The  vao-inal  portion  of  the  cervix  in  most  cases  is  considerably 
hypertrophied,  and  in  respect  to  length  and  volume  is  much  above 
the  usual  dimensions.  There  are  other  conditions  in  connection  with 
tensile  elongation  of  the  cervix  that  have  an  important  bearing  upon 
the  etiology  and  treatment.  Almost  all  supports  in  the  lower  part  of 
the  pelvis  are  in  a  state  of  great  relaxation,  and,  instead  of  being  reten- 
tive, they  contribute  to  the  aggravation  of  the  al^normal  condition  of 
the  cervix. 

This  is  especially  the  case  with  the  vaginal  walls,  the  vesical  liga- 
ments, connective  tissue,  and  fascia. 

The  perineum  is  either  anatomically  deficient  from  laceration,  or 
destitute  of  that  tonicity  which  makes  it  capable  of  resisting  the  pro- 


*  Gynecological  Transactions,  1879. 


ELONGATION    OF    THE   SUPRAVAGINAL    CERVIX.  449 

trusion  of  the  cervix.  In  contrast  with  this  the  supporting  apparatus 
in  the  upper  part  of  the  pelvis  retains  its  natural,  if  it  is  not  endowed 
with  more  than  normal  retentive  power. 

The  treatment  of  this  form  of  elongated  cervix  will  depend  some- 
what upon  the  time  it  has  lasted,  the  extent  of  the  elongation,  and  the 
relaxation  of  the  perineum. 

When  the  lesion  is  of  recent  origin,  and  the  perineum  has  not  been 
lacerated,  and  possesses  a  reasonable  amount  of  resistance,  we  may- 
hope  to  succeed  in  restoring  the  shape  and  size  of  the  cervix  by  prop- 
erly supporting  it  with  a  pessary.  In  selecting  an  instrument  for  this 
purpose  it  will  not  often  do  to  choose  one  that  has  its  bearings  wholly 
upon  the  perineum,  but  one  that  is  partially  maintained  in  position 
by  external  means. 

In  the  hands  of  most  practitioners,  I  believe  Cutter's  or  Scott's  will 
fulfil  the  purpose  more  certainly  than  any  other.  While  both  of 
them  rest  upon  the  perineum,  they  may  be  so  adjusted  that  they  will 
not  bear  upon  it  with  much  weight.  If,  however,  the  perineum  is 
in  a  lacerated  or  greatly  relaxed  state,  we  must  depend  mainly  upon 
surgical  means,  and  as  the  result  of  ray  own  observation,  I  do  not 
hesitate  to  indorse  the  practice  of  Goodell  as  set  forth  in  the  paper 
above  referred  to,  viz.,  to  amputate  the  vaginal  cervix  and  operate 
upon  the  perineum  afterward  if  necessary.  I  do  not  consider  it  neces- 
sary to  remove  the  cervix  at  the  vaginal  attachment,  but  think  it 
better  to  leave  a  margin  of  one-fourth  of  an  inch.  Great  care  is  neces- 
sary in  removing  the  cervix  in  this  condition  to  avoid  wounding  the 
bladder  or  opening  the  peritoneal  cavity. 

Whether  the  amputation  is  done  with  '  scissors,  knife,  galvano- 
cautery,  or  ecraseur,  we  should  take  measures  to  secure  ourselves 
against  this  accident.  The  most  convenient  way  to  do  this  is  to  pass 
two  strong  steel  wires  through  the  cervix  slightly  below  the  junction 
of  the  vagina  and  cervix.  The  wire  or  chain  of  the  ecraseur  may  be 
applied  close  up  to  this  wire ;  this  will  prevent  any  traction  upon  one 
part  more  than  another.  The  scissors  may  be  used  and  the  cervix 
amputated  according  to  the  method  of  Sims  (Figs.  217  and  218),  who 
draws  the  mucous  membrane  over  the  stump  and  unites  it  with  four 
sutures,  two  on  each  side  of  the  cervix.  Hegar  similarly  unites  the 
edges  of  the  sides,  but  also  unites  the  edges  of  the  cervical  mucous 
membrane  with  the  vaginal  edges  opposite  by  two  or  three  on  the  ante- 
rior, and  the  same  number  on  the  posterior  cervical  walls  in  the  middle 
portion.  The  patient  must  remain  in  bed  several  weeks  to  secure  the 
best  results.  Simon  operated  by  cutting  a  wedge  from  each  lip  (Fig. 
219)  and  uniting  the  raw  surfaces.  This  method  is  more  applicable  to 
cases  in  which  the  cervix  is  thickened  as  well  as  elongated.  As  there 
is  often  more  or  less  cervical  laceration,  Emmet's  operation  for  lacera- 
tion (removing  plenty  of  tissue)  is  sometimes  preferable  to  amputation. 

29 


450 


HYPERTROPHY    OF   THE    CERVIX. 


When  the  perineum  has  been  lacerated  perineorrhaph}'  should  be 
performed  before  the  patient  attempts  to  exercise  on  foot. 


Fig.  217. 


Amputation  of  the  Ccr\i\— aftei  Sims. 


Amputation  of  the  Cervix — Sutures  Tied. 


If  the  perineum  does  not  need  restoration,  and  there  should  be  any 
tendency  to  continuance  of  supravaginal  elongation  after  the  opera- 
tion, Scott's  pessary  should  be  introduced,  to  supply  the  support  that 
the  perineum  in  a  healthy  condition  would  give. 


Fig.  219. 


Simon's  Method  of  Amputating  the  Cervix. 


Success  in  this  operation  will  depend  very  greatly  upon  the  treat- 
ment and  care  the  parts  receive  for  some  time  after  the  patient  resumes 
the  erect  posture  and  her  usual  exercise. 


CHAPTER   XXV  I. 

ACUTE  PERIMETRITIS. 

I  USE  the  term  perimetritis  to  signify  inflammation  of  the  tissues 
surrounding  the  uterus,  and  include  both  cellulitis  and  local  perito- 
nitis under  this  head. 

There  is  an  abundance  of  areolar  tissue  in  the  pelvis.  It  is  be- 
tween the  bladder  and  pubis,  the  bladder  and  vagina,  the  vagina  and 
rectum,  but  in  greater  amount  between  the  sides  of  the  vagina,  uterus, 
and  bladder,  and  the  pelvic  bones.  (See  p.  23,  Figs.  7,  8,  9.)  In  a 
loose  manner  it  fills  up  the  space  indicated.  Within  the  folds  of  the 
peritoneum,  the  ovaria,  the  Fallopian  tubes,  and  the  round  ligament 
are  included  with  the  cellular  tissue.  Inflammation  attacks  this  areo- 
lar tissue  not  unfrequently  on  one  side,  and  involves  the  tube,  the 
ovary,  ligament,  and  peritoneal  covering ;  less  frequently  both  sides 
are  simultaneously  inflamed,  and  still  less  often  that  part  between 
some  of  the  hollow  organs  of  the  pelvis  is  affected,  when  we  have  a 
comparatively  small  point  of  disease,  as,  for  instance,  between  the 
'bladder  and  vagina,  or  this  last  and  the  rectum.  This  is  perimetritis. 
There  is  a  strong  tendency  when  inflammation  is  lighted  up  in  any 
part,  to  spread  to  the  space  at  the  side  of  the  uterus  and  vagina  cov- 
ered by  the  broad  ligament,  on  one  or  both  sides.  The  inflammation 
is  apt  to  run  its  course  rapidly,  as  is  usual  in  areolar  tissue,  either  to 
resolution  or  suppuration,  and  as  this  tissue  is  abundant,  and  the 
organs  in  the  pelvis  easily  moved,  the  effusive  products  are  likely  to 
be  copious.  In  the  first  stage  of  inflammation,  serum  is  rapidly 
poured  out  between  the  folds  of  the  peritoneum  by  the  side  of  the 
uterus  and  vagina ;  it  pushes  these  organs  to  one  side  of  the  pelvis, 
and  forms  a  prominent  inflammatory  tumefaction  at  the  side  of  the 
pelvic  cavity,  within  easy  reach  of  the  finger.  This  tumidity  becomes 
harder  in  a  short  time,  and  forms  a  solid  medium  of  connection  be- 
tween the  uterus  and  wall  of  the  pelvis,  indicating  the  change  from 
serous  to  fibrinous  effusion.  Within  a  week  or  ten  days,  in  very 
acute  cases,  in  others  from  two  to  four,  or  even  six  weeks,  the  areolar 
tissue  is  broken  down  into  copious  suppuration.  In  some  instances 
the  suppuration  does  not  advance  beyond  the  stage  of  serous  effusion. 
When,  after  lasting  for  an  uncertain  time,  the  symptoms  begin  to 
subside,  the  tumefaction  disappears,  and  the  patient  soon  recovers  her 
health;  while  in  others  it  is  arrested  after  fibrinous  infiltration  has 
cemented   the  parts  solidly  together.     Although  the  symptoms  are 


452  ACUTE    PEEIMETEITIS. 

moderated  from  their  first  acuteness  when  this  is  the  case,  some  of 
them,  as  undue  sensitiveness  and  sense  of  weight,  and  other  kinds 
of  pelvic  distress,  remain  for  a  considerable  time,  and  the  patient  re- 
covers from  the  attack  very  slowly,  if  ever  completely.  When  sup- 
puration takes  place,  if  it  is  completely  and  readily  evacuated,  the 
patient  very  soon  regains  her  health  and  strength.  In  some  patients 
of  broken-down  or  damaged  constitutions,  sloughing  and  extensive 
ulceration  increase  the  damage  to  the  organs.  I  once  saw  a  syphilitic 
patient  in  whom  extensive  and  rapidly  spreading  ulceration  opened 
the  rectum,  vagina,  bladder,  and,  finally,  the  peritoneal  cavity.  Sup- 
puration in  this  case  was  unhealthy  and  ichorous,  smelling  strongly, 
and  produced  excoriation  of  the  parts  over  which  it  flowed.  If  the 
evacuation  of  the  jdus  is  imperfect  on  account  of  opening  into  the 
rectum  or  bladder,  and  even  in  the  vagina,  the  symptoms  may  be 
prolonged  for  months  and  even  years.  And  in  some  cases  where  the 
evacuation  of  the  pus  and  subsidence  of  the  inflammation  seemed 
complete,  the  disease  recurs  usually  with  diminished  acuteness  a  num- 
ber of  times.  I  once  had  a  patient  in  whom  an  attack  of  perimetritis 
was  contemporaneous  with  incipient  pregnancy  for  four  different  times 
while  under  my  care.  In  each  one  of  these  four  times,  the  inflam- 
mation commenced  at  about  the  time  the  menstrual  flow  ought  to 
have  appeared  after  conception.  Every  time  there  was  copious  sup- 
puration, a  free  discharge  of  the  pus,  and,  to  all  appearance,  a  com- 
plete recovery  from  the  inflammation.  The  intervals  were  about  two 
years  in  duration.  I  have  seen  three  instances  in  which  the  recurrence 
of  the  inflammation  had  occurred  at  irregular  intervals  from  three 
months  to  a  year  for  over  six  years,  another  ten,  and  one  as  much  as 
eighteen  years.  In  this  last  case,  the  abscess  was  situated  at  the  left 
side  of  the  uterus,  and  usually  after  a  week  or  ten  days  of  acute  suf- 
fering, it  discharged  about  a  half  ounce  of  fetid  pus,  and  then  disap- 
peared, so  that  nothing  but  a  slight  induration  at  the  point  mentioned 
indicated  any  tendency  to  its  recurrence.  This  chronic  form,  I  think, 
is  not  very  uncommon.  I  believe,  also,  that  chronic  induration  in 
the  spaces  occupied  by  the  pelvic  areolar  .tissue,  caused  by  fibrinous 
infiltration,  not  unfrequently  presents  itself  as  the  effect  of  acute  peri- 
metritis, producing  many  distressing  symptoms,  and  rendering  the 
patient  liable  to  a  recurrence  of  acute  attacks.  The  extent  of  the  in- 
flammation and  tumefaction  is  governed  somewhat  by  the  condition 
of  the  jDatient.  If  she  be  in  the  puerperal  state,  the  inflammatory 
excitement  is  likely  to  be  greater,  the  swelling  more  extensive,  and 
the  suffering  more  severe,  than  if  this  condition  is  not  present.  Preg- 
nancy increases  the  intensity  of  the  disease  beyond  what  it  is  in  the 
unimpregnated  condition;  the  fever  runs  higher,  and  the  extent  of 
the  inflammation  is  greater.     The  same  will  be  the  case  after  abor- 


CELLULITIS.  453 

tions.  The  mildest  form  of  perimetritis  is  that  which  occurs  in  the 
unimpregnated  female. 

When  pus  is  formed,  it  finds  its  way  out  through  several  different 
channels.  First,  and  most  frequently,  through  the  vagina ;  the  wall 
of  the  abscess  nearest  the  vagina  ulcerates  through  into  this  canal, 
and  the  pus  escapes,  first  in  small  quantities,  and  finally  freel}^,  until 
the  whole  is  evacuated;  a  number  of  days,  and  even  weeks,  may 
elapse  before  the  discharge  ceases  and  the  cavity  is  filled  up.  The 
escape  through  the  vagina  is  not  only  the  most  common,  but  this  is 
the  most  favorable  outlet,  as  the  opening  is  generally  pretty  free  and 
permanent.  Second,  in  frequency,  as  the  medium  of  discharge  is  the 
rectum ;  the  pus  makes  its  way  into  this  intestine  generally  at  the 
upper  end  of  the  septum  between  it  and  the  vagina.  The  discharge 
is  comparatively  slow  and  unsatisfactory,  appearing  with  the  stools 
in  small  quantities,  and  continuing  for  a  length  of  time.  The  open- 
ing into  the  bowels  is  almost,  if  not  invariably,  valvular  and  tottuous, 
permitting  the  escape  with  difficulty.  If  there  does  not  occur  a 
second  opening  into  the  vagina,  the  abscess  will  generate  pus  almost 
as  fast  as  discharged,  and  we  may  expect  times  of  partial  relief  and 
exacerbation  for  months  and  even  years.  I  am  acquainted  with  an 
instance  in  which  the  patient  has  not  been  entirely  free  from  suffering 
from  this  cause  for  the  last  six  years,  and  a  number  of  times  has  been 
prostrated  for  weeks.  But  few  days  pass  without  the  patient  observ- 
'ing  matter  in  the  fecal  evacuations.  The  pus  makes  its  way  at  other 
times  through  the  inguinal  regions ;  sometimes  it  points  in  one  of  the 
labia,  or  burrows  through  the  gluteal  region.  It  also  jDerforates  the 
uterus  or  bladder,  and  follows  the  channels  leading  from  them  out- 
wardly. When  the  pus  finds  its  way  into  any  of  these  hollow  organs, 
it  causes  severe  irritation  in  them  and  efforts  at  expulsion.  Dysuria, 
dysentery,  and  vaginitis  are  generally  caused  by  it  to  a  moderate  de- 
gree, but  sometimes  the  suffering  from  this  cause  in  these  organs  is 
very  great.  But  another  mode  of  escape  from  the  cavity  of  the  ab- 
scess is  into  the  peritoneal  sac.  This  misfortune  is  comparatively 
infrequent,  fortunately,  but  invariably  fatal  unless  relieved  by  lapa- 
rotomy. I  have  been  unfortunate  enough  to  be  connected  with  two 
cases  in  which  this  untoward  circumstance  occurred. 

One  of  the  patients  was  attacked  in  the  puerperal  state,  and,  after 
suffering  for  eight  weeks  with  the  inflammation  of  the  tissues  around 
the  uterus,  acute  general  peritonitis  terminated  her  life  in  about 
thirty-six  hours  from  the  time  it  commenced.  Upon  examining  the 
abdominal  cavity,  an  opening  was  found  near  the  left  sacro- iliac 
junction,  which  communicated  with  the  interior  of  the  abscess,  and 
several  ounces  of  jdus  was  in  the  cavity  of  the  peritoneum,  that  had 
made  its  way  through  this  opening.  The  usual  lesions  of  extensive 
and  acute  peritonitis  gave  evidence  of  the  cause  of  death.     The  other 


454  ACUTE    PERIMETEITIS. 

case  was  in  a  sterile  married  woman,  about  twenty-five  years  of  age, 
who  had  been  treated  three  weeks  for  typhoid  fever.  Dissection 
revealed  a  large  pelvic  abscess,  with  recent  rupture  into  the  peritoneal 
cavity,  and  extensive  peritoneal  lesions.  This  overwhelming  perito- 
neal inflammation  lasted  only  about  eighteen  hours  before  the  death 
of  the  patient.  When  the  peritoneal  symptom  supervened,  it  was 
regarded  as  the  result  of  the  intestinal  ulceration  which  sometimes 
so  suddenly  terminates  typhoid  fever. 

Causes. 

Perimetritis  occurs  as  a  sequel  to  abortions  and  labor  at  full  term, 
and  there  is  but  little  doubt  but  that  these  two  conditions  sometimes 
predispose  to  the  disease.  The  menstrual  congestion  seems  to  do  the 
same  thing.  Any  circumstance  that  fills  the  pelvis  with  blood  in 
active  congestion  may  so  predispose  to  it.  Cold  suddenly  apj)lied 
to  the  surface  or  to  the  feet  and  legs  may  excite  the  already  congested 
parts  into  a  state  of  inflammation.  Much  exercise  of  the  limbs  in 
walking  or  standing  on  them  for  a  long  time,  when  the  pelvic  vessels 
are  already  distended  and  excited,  has,  on  some  occasions,  seemed  to 
me  to  awaken  inflammation.  The  incautious  use  of  strong  caustics 
to  the  cervix  uteri  may  give  rise  to  it.  I  think  I  saw  a  case  in  which 
perimetritis  was  brought  about  by  severe  exercise  in  walking  imme- 
diately after  the  use  of  caustic  potassa.  Excessive  venereal  indul- 
gence predisposes  to  this  inflammation,  if  it  does  not  produce  it  alone.* 

Symptoms. 

The  patient  is  attacked  suddenly,  usually  with  pain  in  the  pelvis, 
hyjDOgastrium,  or  iliac  regions,  which  radiates  to  the  sacrum,  loins, 
and  abdomen.  Sometimes  it  passes  down  one  extremity,  or  there  is 
pain  in  both  legs.  The  pain,  generally  at  first  aching  and  moderate, 
may  become  very  severe,  and  darting  or  cramping  in  character.  In 
the  beginning,  or  after  the  inflammation  has  lasted  a  little  while, 
there  is  pain  or  difficulty  in  urinating ;  by  ijressing  upon  the  inflamed 
parts,  the  passage  of  faeces  through  the  rectum  is  painful.  The  patient 
usually  experiences  a  sense  of  weight  about  the  perineum,  and  drag- 
ging in  the  loins  and  hips.  All  the  pains  are  much  aggravated  by 
motion,  or  assuming  and  continuing  in  the  erect  posture.  Pressure 
over  the  epigastric  and  inguinal  portions  of  the  abdomen  increases 
the  pain  and  suffering. 

At  the  commencement  of  the  pain  the  patient  is  attacked  with 
rigors  of  greater  or  less  severity.     The  chilliness  may  be  slight,  but 

*  See  Chapter  XX.  for  other  causes. 


CELLULITIS.  455 

often  it  amounts  to  severe  shaking  and   trembling  ;  reaction  propor- 
tionate to  the  intensity  of  the  chill  succeeds ;    the  head  aches,  the 
limbs  are  pained,  the  skin  is  hot  and  dry,  and  the  tongue  coated,  and 
the  mouth  dry  and  parched.     These  symptoms  may  come  on  very 
suddenly,  and  the  case  be  well  marked  in  a  few  hours  from  the  time 
they  commence,  or  so  moderately  and  gradually  as  to  be  several  days 
in  assuming  prominence.     In  puerjDeral  patients  they  occur  generally 
several  days  after  confinement,  and  seem  to  be  induced  by  undue 
exertion  or  exposure.     In  such  cases  the  symptoms  are  more  intense 
than  in  the  non-puerperal   cases.     The  pulse  is  rapid,  the  nervous 
system  much  disturbed,  the  heat  great,  and  often  there  is  delirium. 
The  high  febrile  excitement  is  attended  with  severe  pain,  extending 
in  various  directions.     Tumefaction  and  tenderness  over  the  lower 
parts  of  the  abdomen  indicate  a  local  peritoneal   inflammation   in 
many  of  the  more  severe  instances,  although  this  is  not  always  the 
case.      Some  of  these  puerperal    cases  so  closely  resemble   cases  of, 
metroperitonitis — if  they  are  not  so  indeed — that  the  cases  are  re- 
garded as  attacks  of  puerperal  fever.     So  intense  are  the  symptoms 
as  apparently  to  jeopardize  the  life  of  the  patient  immediately  by 
the  gravity  of  the  general  pelvic  and  abdominal  inflammation.     And 
when  the  tumefaction  and  tenderness  of  the  abdomen  subside,  the 
febrile  reaction  is  moderated  or  becomes  more  paroxysmal,  we  find 
a  hard  tumor  generally  on  one  side   dipping  down  into  the  pelvis 
.and  extending  sometimes  to  the  ribs  and  across  to  the  umbilicus; 
or  it  may  be  developed  in  the  mesial  portion  of  the  abdomen  and 
pelvis,   extending   upward   to   a   greater  or  less  degree.     Tumors  of 
this  kind  are  tender,  and  may  be  detected  in  the  pelvis  by  a  vagi- 
nal  examination.      They   do   not   always   suppura^-e,   but  generally 
disappear  by  absorption.     At  other  times  they  produce  copious  quan- 
.  titles  of  pus.    This  inflammation  sometimes  dissects  up  the  peritoneum 
over  the  osseous  iliac,  and  lumbar  muscles,  to  a  great  extent,  dissolv- 
ing out  the  areolar  tissue  in  a  large  space.     The  distension  and  ten- 
derness are  quite  frequently  confined  to  one  side,  showing  the  point 
of  greatest  intensity  of  the  disease,  but  we  often  find  them  extending 
entirely  across,  and  sometimes  considerably  up  the  abdomen.     These 
symptoms  appertain  to  the  first  stage,  and  last  for  from  four  or  five 
days  to  two  weeks,  and  in  rare  cases  longer,  when  they  are  gradually 
succeeded  by  those  that  indicate  the  suppurative  stage.     The  pain  be- 
comes less  acute,  and  changes  ordinarily  to  a  burning  character,  quite 
as  distressing,  if  not  more  so,  than  at  first.     It  is  worse  at  night,  and 
prevents  the  patient  from  resting.     The  fever  assumes  something  of  a 
remitting  type.     It  is  more  intense  in  the  evening  and  night ;  toward 
morning  a  moisture  is  observed  upon  the  skin,  the  heat  becomes  less, 
and  there  is  some  amelioration  in  the  suffering.     After  a  little  longer 
the  paroxysms  are  very  marked ;  chilliness  in  the  afterpart  of  the  day 


456  ACUTE   PERIMETRITIS. 

is  succeeded  by  a  very  rapid  pulse  and  intense  heat  of  the  surface. 
This  fever  lasts  for  six  or  eight  hours,  and  is  resolved  by  a  copious 
perspiration.  These  perspirations  are  accompanied  with  great  lan- 
guor and  depression.  The  patient  is  debilitated  and  much  worn  by 
the  continuance  of  the  symptoms.  At  length,  after  days  of  this  ex- 
hausting, suppurative  fever,  the  pus  makes  its  way  through  the  walls 
of  the  abscess,  and  is  discharged  through  some  of  the  outlets  men- 
tioned above.  If  the  evacuation  is  free,  and  the  discharge  consider- 
able, the  relief  is  very  great  indeed,  the  fever  subsides,  the  perspiration 
ceases,  the  spirits  are  good,  the  appetite  becomes  excellent;  in  fact, 
the  change  in  the  patient  is  very  great  and  gratifying.  Convalescence 
is  now  established,  and  in  a  few  days  all  the  serious  and  distressing 
symptoms  vanish.  If  the  discharge  is  not  free,  and  but  a  small  quan- 
tity of  the  matter  escapes,  although  there  is  relief,  it  is  not  so  complete. 
The  patient  is  temporarily  better,  but  not  convalescent.  The  opening 
is  not  sufficient,  the  pus  continues  to  increase  and  imperfectly  dis- 
charge, and  fluctuations  in  the  intensity  of  suffering  continue  to  inspire 
hope  and  cause  depression,  until  a  freer  opening  occurs  in  the  same 
place,  or  another  one  allows  the  pus  to  escape  more  freely. 

This  description  is  intended  to  apply  to  cases  of  considerable  in- 
tensity in  the  puerperal  or  non-puerjDcral  patient.  But  the  degrees  of 
intensity  are  very  different  in  different  instances.  Sometimes  the 
symptoms  are  so  slight  as  to  scarcely  attract  attention,  until  the  dis- 
charge begins  to  make  its  appearance.  At  other  times  there  is  dis- 
tressing fever,  but  the  local  symptoms  are  so  poorly  marked  that  the 
case  is  misapprehended.  I  have  known  the  fever  to  last  for  three  or 
four  weeks,  ending  in  hectic,  with  its  exhausting  accompaniments, 
before  the  true  nature  of  the  case  was  discovered. 

An  example  of  the  occasional  insidiousness  of  the  non-puerperal 
form  of  this  affection  is  exhibited  in  the  following  case : 

Mrs.  A ,  aged  twenty-four,  married  two  months,  has  suffered  for 

the  last  four  years  with  moderate  dysmenorrhoea,  and  occasional  leu- 
corrhoea.  Sexual  intercourse  has  given  her  much  pain  from  the  first 
since  her  marriage ;  after  three  weeks  the  pain  in  the  coitus  became 
intolerable.  At  this  time  she  had  severe  pain  in  the  back  and  pelvic 
region  constantly,  but  not  so  severe  as  to  prevent  her  being  about  in 
the  attention  to  domestic  duties  and  taking  a  short  trip  by  rail  with 
her  husband.  She  had  some  very  slight  febrile  reaction,  with  sense 
of  chilling,  for  about  twenty  days,  when  the  paroxysms  assumed 
something  of  a  hectic  character,  lasting  from  three  o'clock  until  seven 
or  eight  p.m.,  terminating  with  copious  diaphoresis.  A  little  later  a 
very  severe  pain  in  the  hypogastric  region  was  developed,  attended 
with  frequent  efforts  at  urination.  In  about  four  days  from  the  super- 
vention of  this  pain  she  began  to  pass  pus  in  large  quantities  in  the 
urine,  together  with  marked  quantities  of  blood.     Upon  making  ex- 


CELLULITIS.  457 

amination  at  this  time  the  pelvis  on  the  right  side  and  front  portion 
was  filled  by  a  tumefaction  very  tender  to  the  touch,  which  had 
crowded  the  uterus  back  uj)on  the  rectum  and  down  so  that  the  os 
was  in  contact  with  the  perineum.  These  symptoms  and  the  exami- 
nation fully  declared  it  a  case  of  cellulitis. 

Diagnosis. 

Although  the  symptoms,  in  most  cases,  are  severe  and  sufl&ciently 
prominent,  they  are  not  often  distinctive.  Several  other  affections 
resemble  it  in  many  symptoms.  Hence,  the  only  way  to  arrive  at 
correct  diagnosis  is  by  physical  examinations.  The  finger  Avill  be  the 
only  instrument  necessary.  It  is  cruel  to  use  the  speculum,  while  it 
affords  us  no  aid  in  the  vast  majority  of  cases.  I  should  not  think  it 
necessary  to  caution  the  reader  against  the  use  of  this  instrument  if  I 
had  not  seen  it  resorted  to  more  than  once,  to  the  great  torture  of  the 
patient.  In  making  examinations  for  this  kind  of  case,  the  patient 
should  be  so  placed  that  we  may  use  both  hands  if  necessary.  When 
one  or  two  fingers  are  introduced  into  the  vagina,  they  will  detect  un- 
usual tumidity  in  the  pelvis.  Sometimes  this  tumidity  extends  to  the 
bottom  of  the  pelvis  on  one  side,  and  occasionally  apparently  fills 
up  the  whole  lower  part  of  the  pelvic  cavity ;  at  other  times  the  tu- 
midity is  circumscribed  and  confined  to  one  side  high  up,  or  before 
the  uterus.  The  tumefied  parts  are  generally  hard,  and  very  tender 
to  the  touch,  so  that  a  small  amount  of  pressure  causes  great  suffer- 
ing ;  the  uterine  neck  is  almost  always  pushed  to  one  side,  backward, 
upward,  or  downward ;  the  vagina  is  generally  hot  and  dry,  and  all 
the  parts  sensitive.  If  we  place  one  hand  above  the  pelvis,  while  the 
fingers  of  the  other  are  in  the  vagina,  we  will  have  a  consciousness  of 
a  tumor  between  the  fingers  of  the  two  hands. 

It  is  not  always  the  case  that  any  tumidity  can  be  felt  above  the 
superior  strait,  but  generally  there  is  tumefaction  in  one  iliac  region 
or  sometimes  in  both.  The  tumefaction  may  extend  much  above 
these  regions,  high  up  into  the  abdominal  cavity,  though  not  often. 
If  the  tumefaction  is  considerable,  the  uterus  is  firmly  fixed  in  its 
place,  but  when  less,  this  is  not  the  case.  In  childbed  patients  we 
may  distinguish  cellulitis  from  i3eritonitis  by  digital  examination  per 
vaginam.  There  is  not  the  hard  tumefaction  in  the  pelvis  in  the  last 
as  in  the  first.  Tenderness  and  general  distension  of  the  abdomen 
are  greater  in  peritonitis;  the  pulse  is  more  rapid  and  is  peculiar. 
These  may  and  probably  are  often  combined  in  puerperal  fever,  when 
the  diagnosis  is  of  less  importance  than  when  they  are  separate 
affections.  The  general  peritoneal  inflammation  supervenes  after 
delivery  much  earlier — generally  on  the  second  day — than  any  of  the 
localized  inflammations  do.     Cellulitis  is  more  likely  to  attack  the 


458  ACUTE    PERIMETRITIS. 

patient  when  or  after  she  begins  to  make  exertion,  or  is  exposed  to 
cold  several  days,  six  to  ten,  and  even  more  after  delivery.  (See 
Pelvic  Peritonitis,  p.  460.) 

From  acute  metritis  in  the  puerperal  or  non-puerperal  state,  it  may 
be  distinguished  by  examination  with  the  finger.  There  is  not  much 
difference  in  the  mode  of  attack  and  history  between  acute  metritis 
and  perimetritis;  but  by  a  careful  survey  of  the  jDelvic  organs,  we 
may  separate  the  inflamed  from  the  sound  parts.  In  metritis  the 
uterus  is  generally  and  symmetricalh^  enlarged,  and  extends  lower 
down  in  the  pelvis,  and  if  touched  at  any  point  is  tender ;  in  cellulitis 
this  organ  is  not  generally  enlarged,  and  if  touched  an3"where  in  such 
manner  as  not  to  press  it  against  or  move  it  on  the  side  where  the 
inflammation  exists,  is  not  the  subject  of  painful  impressions.  The 
tenderness  in  cellulitis  is  generally  to  one  side  of  the  uterus,  close  to 
the  walls  of  the  pelvis.  If  the  inflammation  is  in  the  badder,  we 
may  easily  ascertain  this  fact,  by  pressing  this  organ  between  the 
fingers  in  the  vagina  and  those  above  the  symphysis  pubis.  From 
metatithmenia  it  is  distinguishable  by  the  tenderness  and  firmness  of 
the  tumor,  the  febrile  symptoms,  and  the  history  of  the  two  condi- 
tions; cellulitis  being  previously  inflammatory,  while  metatithmenia, 
when  inflammatory  at  all,  becomes  so  some  time  after  the  commence- 
ment of  the  symptoms.  The  blood}^  tumor  may  be  handled  without 
much  pain,  is  soft  and  yielding,  and  commences  at  the  time  of  menstru- 
ating with  sharp  pain  likened  often  to  severe  colic,  without  chill  and 
fever  at  the  beginning ;  sometimes  with  collapse  more  or  less  intense. 
Carcinoma  filling  up  the  lateral  parts  of  the  i^elvis,  is  sometimes 
mistaken  for  cellulitis,  but  more  often  the  latter  is  mistaken  for  the 
former.  Carcinoma  is  insidious  in  its  incipiency.  It  has  made  great 
advance  before  symptoms  indicate  its  existence,  while  cellulitis  is 
heralded  by  inflammatory  symptoms  from  the  start.  The  hardness 
of  carcinoma  is  greater,  the  tumidity  more  irregular  and  devoid  of 
tenderness ;  it  is  not  hot  as  in  inflammation.  The  discharge  from 
carcinoma  when  it  occurs  is  cadaverous  in  odor,  thin  and  ichorous  in 
character.  In  cellulitis  the  discharge  is  pus,  and  if  it  smells  at  all, 
the  odor  is  faintly  fecal.  I  have  noticed  this  last  feature  in  several 
instances  of  perimetritis,  when  the  evacuation  of  the  pus  was  free  and 
copious  through  the  vagina. 

The  diagnosis  from  chronic  metritis  is  not  always  easy.  Wlien 
cellulitis  is  chronic,  it  causes  many  of  the  symptoms  wliich  we  ob- 
serve to  be  present  in  chronic  metritis.  It  will  require  a  careful 
consideration  of  the  symptoms  and  history  of  the  case,  with  physical 
examination. 

Chronic  cellulitis  ordinarily  results  from  an  acute  attack,  that  was 
accompnnied  witli  a  discharge  of  pus  more  or  less  copious,  and  par- 
oxysms of  less  intensity  have  succeeded,  growing  more  mild,  until  the 


CELLULITIS.  459 

symptoms  become  obscure.  Paroxysmal  discharge  of  pus  is  a  com- 
mon sj'mptom  of  chronic  cellulitis.  Upon  a  thorough  and  careful 
examination  of  the  pelvic  cavity,  we  may  find  some  small  spot,  not 
in  contact  with  the  uterus,  but  by  the  side  of  it  ordinarily,  that  is 
hard  and  tender  to  the  touch.  In  chronic  metritis  there  is  not  always 
tenderness. 

Prognosis. 

This  is  generally  favorable.  There  is  probably  more  danger  in 
attacks  during  the  puerperal  condition,  or  after  miscarriage,  than  in 
unimpregnated  patients,  although  the  very  large  majority  of  these 
cases  terminate  favorably.  Of  course  I  leave  out  of  this  considera- 
tion such  instances  as  are  attended  by  general  peritonitis  of  simulta- 
neous origin,  and  constitute  only  a  part  of  the  whole  puerperal  fever. 
I  do  not  think  there  is  much  difference  in  the  fatality  of  uncompli- 
cated cases  occurring  under  these  diverse  circumstances.  When  cellu- 
litis proves  fatal,  it  is  generally  in  one  of  three  ways:  1st.  By  ex- 
haustion caused  by  excessive  and  long-continued  febrile  excitement, 
symptomatic  of  extensive  inflammation.  2d.  The  exhausting  effects 
of  hectic  fever,  diarrhoea,  diaphoresis,  and  want  of  nourishment.  3d. 
Severe  complications,  arising  during  the  progress,  as  peritonitis,  by 
extension  of  inflammation;  or  the  more  rapidly  fatal  form  of  peri- 
tonitis, caused  by  effusion  of  pus  in  its  cavity.  I  have  seen  three 
fatal  cases.  Two  of  them  resulted  from  rupture  of  the  abscess,  and 
discharge  of  the  pus  into  the  peritoneal  cavity.  One  of  these  was 
puerperal,  and  death  occurred  ten  weeks  after  confinement;  the  other 
non-puerperal,  and  ended  in  eight  weeks  from  the  attack.  The  one 
which  proved  fatal  from  exhausing  hectic,  without  evacuation  of  the 
pus,  terminated  in  sixty  days  from  the  commencement. 

A  great  many  cases  terminate  in  the  chronic  form.  The  cause  of 
this  sort  of  termination  is  often  incomplete  evacuation  of  the  pus,  and, 
as  a  consequence,  imperfect  obliteration  of  the  cavity  of  the  abscess. 
The  pus  accumulates  from  time  to  time,  and  fresh  eruptions,  attended 
with  a  greater  or  less  exacerbation  of  the  symptoms,  every  few  weeks 
or  months,  occur  as  this  result.  Or  the  external  opening,  wherever  it 
may  be,  does  not  close,  and  there  is  a  constant  discharge  of  greater  or 
less  quantity,  keeping  up  a  kind  of  fistulous  canal,  leading  generally 
some  distance  to  the  main  seat  of  the  difficulty.  Or  in  still  another 
sort  of  cases,  the  pus  seems  to  be  entirely  evacuated,  and  the  cavity 
obliterated,  and  there  is  nothing  left  but  a  small  point  of  indurated 
tissue,  which  is  the  nucleus  of  inflammatory  action  under  certain 
circumstances,  as  pregnancy,  unusual  excitement  of  the  sexual  organs 
from  other  reasons,  etc. 


460  ACUTE   PERIMETEITIS. 

Local  Peritonitis. 

Post-mortem  examinations,  as  shown  especially  byGoupel,  demon- 
strate the  fact  that  we  may  have  peritonitis  confined  to  the  pelvis  and 
its  vicinity.  Observing  practitioners  of  long  experience  must  have 
met  with  instances  which,  without  any  great  difl&culty,  could  be  classed 
under  this  head,  and  I  have  no  doubt  of  the  practicability  of  generally 
distinguishing  them  from  those  of  cellulitis,  with  which  they  are  most 
likely  to  be  confounded. 

Pelvic  peritonitis  is  seldom  primary  and  simple.  More  frequently  it 
is  primary,  and  leads  to  cellulitis  as  a  complication ;  and  in  other  cases 
it  is  secondary,  and  a  consequence  of  pre-existing  cellulitis,  and  there- 
fore complicated  with  it. 

Post-mortem  examinations  are  not  always  conclusive  as  indicating 
a  condition  which  had  existed  during  the  entire  course  of  the  disease; 
for  while  in  the  more  acute  stages  there  may  have  been  coexisting  in- 
fiamniation  of  the  peritoneum  and  cellular  tissue,  the  inflammatory 
action  in  the  cellular  tissue  may  have  subsided,  and  the  peritonitis 
alone  remain  to  be  discovered  at  the  autopsy,  and  vice  versa. 

This  would  mislead  the  pathologist  who  depended  upon  the  post- 
mortem appearances  entirely. 

When  the  peritoneum  is  primarily  attacked,  and  the  inflammation 
is  confined  to  this  membrane,  it  becomes  injected  with  blood,  dry,  and 
rough,  and  in  the  motion  to  which  the  viscera  are  subjected  during 
respiration,  etc.,  the  surfaces  rub  together  and  cause  sharj)  stabbing 
pain.  Upon  the  subsidence  of  this  stage  of  the  inflammation,  an  effu- 
sion of  serum,  rich  in  fibrin,  takes  place,  which  gravitates  to  the  most 
dependent  part,  and  usually  accumulates  in  the  cul-de-sac  behind  the 
uterus,  but  does  not  displace  the  organ  to  any  marked  degree.  The 
effused  fluid  soon  coagulates,  and  the  liquid  portion  of  the  serum  is 
removed  by  absorption,  and  there  is  a  solid  mass  of  fibrin  left  in  the 
retrouterine  pouch. 

If  the  uterus  happens  to  be  retroverted  at  the  time  of  the  coagula- 
tion, it  is  fixed  in  that  position  during  the  life  of  the  patient  or  until 
absorption  liberates  it. 

The  movements  of  the  pelvic  organs — and,  by  the  way,  these  organs 
are  always  in  motion  in  unison  with  the  respiratory  movements,  and 
as  an  effect  of  the  movements  of  the  body — sometimes  modify  the  form 
of  the  coagulum,  drawing  it  out  into  bands,  which  stretch  from  one 
surface  to  the  other. 

After  this  serous  efl'usion,  the  inflammation  may  subside  and  leave 
the  patient  comfortable,  but  the  subject  of  a  fixed  uterus.  In  some 
cases,  however,  the  absori:)tion  is  rapid,  and  the  organ  is  left  entirely 
free  in  a  short  time. 

Should  the  inflammation  be  more  intense,  the  epithelium  of  the 


LOCAL   PERITONITIS.  •  461 

membrane  is  loosened  and  falls  off,  leaving  a  pyogenic  surface,  from 
which  pus  is  produced  in  greater  or  less  quantities  when  there  is  a 
sero-purulent  effusion  confined  in  an  irregular  fibrinous  capsule. 

If  the  pus  is  considerable  in  quantity  an  abscess  is  the  result,  which 
finds  its  way  out  in  a  manner  similar  to  the  evacuation  of  pus  as  a 
result  of  cellulitis. 

In  the  non-puerperal  moderate  cases  of  local  peritonitis  the  serous 
and  purulent  accumulations  are  confined  to  the  pelvic  cavity,  but  in 
the  puerperal  or  the  more  intense  forms  of  non-puerperal  inflamma- 
tions, these  accumulations  reach  higher  than  the  brim,  and  are  often 
found  in  indurated  patches  in  both  iliac  regions  or  over  the  hypo- 
gastrium.  When  these  accumulations  are  round,  or  shaped  like 
tumors,  they  may  be  mistaken  for  ovarian  or  uterine  neoplasms. 

The  Fallopian  tubes  are  sometimes  constricted  by  these  fibrinous 
bands,  and  a  portion  of  their  cavity  isolated,  in  which  liquid  accumu- 
lations collect,  and  give  rise  to  Fallopian  tumors, — hydrosalpinx. 

Bernutz  and  Goupil  in  some  instances  found  the  ovaries  involved 
in  the  inflammation,  and  either  destroyed  by  suppuration  or  left  in  a 
state  of  chronic  inflammation. 

Causes. 

The  puerperal  condition  at  term,  or  after  abortion,  is  a  very  fre- 
quent, if  not  the  most  frequent,  cause  of  local  peritonitis. 

The  action  of  cold  upon  the  woman,  when  the  pelvic  organs  are 
in  a  state  of  intense  congestion,  just  prior  or  at  the  time  of  menstrua- 
tion, is  also  a  prolific  cause. 

Gonorrhoeal  inflammation,  by  making  its  way  through  the  cavity 
of  the  uterus  and  along  the  Fallopian  tubes  out  upon  the  peritoneum, 
is,  by  common  consent,  taken  to  be  another  one  of  the  causes ;  but 
inflammation  may,  by  contiguity,  also  extend  from  the  uterus  to  the 
peritoneal  membrane.  This  is  the  case,  doubtless,  in  the  puerperal 
condition,  after  the  violence  dotie  to  the  uterus  by  severe  labor  or 
abortion,  and  in  non-puerperal  cases  where  strong  applications  have 
been  made  to  it,  operations,  etc. 

Direct  violence  to  the  retrouterine  portion  of  the  peritoneum  is 
often  done  by  the  injudicious  introduction  of  foreign  substances  by 
the  patient  herself,  excessive  coition,  and  by  rude  and  ill-directed 
attempts  to  replace  the  uterus  by  instruments. 

Symptoms. 

Pain  in  the  pelvis  and  lower  abdomen  is  one  of  the  most  common 
and  distressing  symptoms,  and  this  pain  is  generally  characteristic. 
It  is  sharp,  stabbing,  and  paroxysmal,  or  exacerbating.     The  sharp, 


462  ACUTE    PERIMETRITIS. 

stabbing,  exacerbating  pain  is  accounted  for,  as  before  said,  by  the 
friction  of  the  two  surfaces  of  the  peritoneum,  rendered  dry  and  rough 
by  the  inflammation.  In  cause  and  character  the  pain  resembles 
that  of  the  early  stages  of  pleuritis. 

While  pain  is  one  of  the  most  constant  symptoms,  cases  do  occur 
in  which  there  is  very  little  pain,  probably  because  early  effusion,  or 
some  other  condition,  prevents  the  friction.  Another  consideration, 
which  will  enable  us  to  account  for  the  absence  of  pain,  is  the  great 
difference  in  the  susceptibility  of  different  persons.  However  we 
may  explain  it,  we  know  from  observation  that  pain  is  sometimes 
almost  entirely  absent,  and  then  the  disease  may  be  mistaken  for 
some  other  affection. 

In  the  commencement  there  is  a  sharp  febrile  reaction,  with  its 
attendant  phenomena,  as  quick  pulse,  headache,  delirium,  nervous 
excitement,  and  derangement  of  the  secretory  functions,  etc. 

The  intensity  of  the  excitement  will  depend  very  greatly  upon  the 
suddenness  of  the  attack  and  extent  of  the  tissue  affected  by  the  in- 
flammation ;  greater  when  sudden  and  extensive,  and  less  when  the 
progress  of  the  inflammation  in  the  first  stage  is  slow  and  the  parts 
involved  are  sm.all  in  extent.  The  febrile  reaction  is  usually  high  at 
first,  and  very  much  moderated  as  the  effusion  occurs. 

The  character  of  both  pain  and  febrile  reaction  are  greatly  modified 
by  the  conditions  which  give  rise  to  suppuration.  As  suppuration  is 
established  the  sharp  pain  gives  way  to  a  sense  of  tension,  weight, 
and  heat,  while  the  febrile  movement  becomes  more  remittent  or 
paroxysmal.  Debility,  copious  perspiration,  and  frequent  chills  make 
up  the  items  indicative  of  suppuration. 

These  symptoms  are  partially  or  completely  relieved  by  opening 
the  pyogenic  cavity  and  permitting  the  pus  to  be  discharged.  The 
points  where  the  pus  flows,  as  in  cellulitis,  are  the  upper  part  of  the 
vagina,  rectum,  the  bladder,  inguinal  or  femoral  canal,  some  place  in 
the  abdominal  wall,  the  gluteal  region,  or  one  of  the  greater  lij)S  of 
the  vaginal  orifice,  and  rarely  the  peritoneal  cavity. 

If  suppuration  does  not  occur,  and  the  case  terminates  in  convales- 
cence without  it,  the  symptoms  gradually  subside. 

Upon  examining  the  lower  abdominal  region  we  will  generally  find 
tenderness  upon  pressure,  and  often  more  or  less  tumef^iction,  with  or 
without  tympanitis.  The  uterus,  if  displaced,  is  pressed  forward,  but 
it  often  occupies  its  normal  position.  In  the  first  stage  there  is  gen- 
erally not  much  tumefaction  in  the  pelvis  felt  through  the  vagina,  but 
great  tenderness  behind  and  by  the  sides  of  the  uterus.  When  the 
fingers  are  pressed  well  upward  in  the  stage  of  effusion  there  is  tume- 
faction behind  the  uterus,  and  sometimes  in  the  iliac  and  hypogastric 
regions. 


LOCAL    PERITOXITIS.  463 


Diagnosis. 


When  free  from  complications, — which,  I  must  say,  judging  from 
my  own  observations,  I  believe  to  be  less  frequent  than  the  converse, 
— I  do  not  see  why  there  should  be  any  great  difficulty  in  differen- 
tiating local  peritonitis.  The  affection  with  which  it  is  more  likely  to 
be  confounded  than  any  other  is  cellulitis.  The  pain  in  the  first  stage 
of  cellulitis  is  more  steady ;  is  dull  or  aching,  instead  of  stabbing  or 
lancinating :  and  the  tenderness,  although  considerable,  is  not  so  great 
as  in  j)elvic  peritonitis.  In  the  second  stage  the  pain  in  the  two 
affections  does  not  differ  much,  if  at  all.  The  tumefaction  is  not  in 
the  same  locality ;  in  cellulitis  it  is  by  the  side  or  in  front  of  the 
uterus,  while  in  local  peritonitis  it  is  behind  that  organ. 

If  the  peritonitis  extends  above  the  pelvis,  which  it  often  does,  it 
may  be  in  one  or  both  iliac  cavities,  or  extend  across  the  lower  part 
of  the  abdomen.  When  the  effusion  in  peritonitis  is  above  the  pelvis 
in  the  centre  percussion  will  elicit  marked  resonance,  because  the  in- 
testines are  contained  in  the  mass,  and  this  resonance  will  enable  us 
to  distinguish  it  from  a  tumor. 

The  history,  symptoms,  and  physical  signs  enable  us  to  decide  be- 
tween local  peritonitis  and  retrouterine  hsematocele.  In  peritonitis 
the  history  is  one  of  inflammation,  well  marked  in  the  beginning  and 
throughout  its  whole  progress,  while  that  of  hsematocele  does  not 
indicate  inflammation  in  the  beginning  of  the  attack,  and  seldom  in 
any  of  its  later  stages.  In  local  peritonitis  metrorrhagia  is  not  a 
symptom ;  in  hsematocele  it  is.  Tenderness  is  a  permanent  feature 
in  peritonitis,  while  it  is  very  slight  if  it  is  present  in  hsematocele. 
This  remark  applies  when  pressure  is  made  above  the  symphysis  or 
in  the  vagina.  The  pelvic  tumors  in  both  disorders  are  ordinarily 
retrouterine,  and  not  dissimilar  in  shape ;  but  in  the  earlier  periods 
the  hsematocele  is  uniformly  soft,  while  the  inflammatory  effusion  is 
harder.  The  hsematocele  displaces  the  uterus  more  than  the  inflam- 
matory product.  The  tumors  caused  by  both  may  and  often  do  ex- 
tend above  the  pelvic  brim.  The  bloody  tumor  is  generally  central, 
and  forms  a  somewhat  level  line  across  the  lower  abdomen,  while  the 
inflammatory  tumor  is  usually  irregular  and  hard,  and  is  often  con- 
fined to  one  iliac  region. 

In  retrouterine  pregnancy  the  absence  of  acute  inflammatory  symp- 
toms, unless  in  exceptional  cases,  and  the  presence  of  the  evidences  o-f 
pregnancy,  are  strong  differentiating  circumstances,  and  will  generally 
lead  to  definite  conclusions.  In  extrauterine  pregnancy  we  can  watch 
the  case  for  a  sufficient  length  of  time,  and  the  growth  of  the  tumor 
will  do  much  to  solve  the  difficulty. 

The  pelvic  tumors  formed  by  cancer  differ  from  those  of  local  peri- 
tonitis in  the  facts  that  they  have  no  inflammatory  history,  in  their 


464  ACUTE    PERIMETRITIS. 

great  hardness  and  irregularity  of  growth.  Fibrous  tumors  have  no 
inflammatory  history,  are  more  or  less  movable,  more  dense  and 
regular  in  outline.  The  fibrous  tumor  is  generally  accompanied  by 
metrorrhagia,  while  the  inflammation  is  not  often  attended  by  that 
symptom. 

Prognosis. 

When  peritonitis  is  confined  to  the  pelvis  and  its  vicinity  it  is  rarely 
fatal.  One  of  the  dangers  connected  with  it  is  the  probability  of  its 
extension  to  the  whole  or  greater  part  of  the  abdominal  peritoneum. 
This  is  much  more  likely  to  occur  in  puerperal  cases.  The  fatal  ter- 
mination is  sometimes  the  result  of  exhaustion  induced  by  protracted 
suppuration  and  febrile  excitement. 

Acute  pelvic  peritonitis  has  a  strong  tendency  to  become  chronic  by 
the  continuance  of  the  inflammation  in  a  subdued  form.  In  this 
condition,  by  exposure,  over- exertion,  sexual  excitement,  or  injudi- 
cious treatment,  it  may  become  intensified  to  an  acute  degree.  When 
pelvic  peritonitis  has  resulted  in  collections  of  pus  in  portions  where 
the  evacuation  of  the  fluid  is  imperfect,  the  inflammation  may  be 
protracted  to  an  indefinite  time.  Fortunately,  however,  in  the  great 
majority  of  cases  it  passes  into  convalescence,  which  is  usually  slow, 
but  complete. 

Before  giving  the  treatment  of  local  peritonitis  I  must  again  say 
that  this  disease  is  so  frequently  complicated  b}^  cellulitis  that  its 
occurrence  in  the  simple  form  is  not  common.  I  believe,  also,  that 
simple  cellulitis  is  as  rare  as  uncomplicated  local  peritonitis.  But  it 
is  very  often  the  case  that  the  cellulitis  is  comparatively  intense,  while 
the  peritonitis  is  not  severe,  when  the  symptoms  and  physical  signs 
are  those  of  cellulitis ;  and  again,  the  peritonitis  may  assume  a  grave 
form,  while  the  cellulitis  exists  in  a  very  moderate  degree,  when  the 
symptoms  of  peritonitis  will  predominate.  The  contiguity  of  the 
tissue  implicated  in  these  two  affections,  and  the  identity  of  vascular 
and  nervous  supply,  are  facts  that  hardly  admit  of  any  other  conclu- 
sion than  that  inflammation  does  not  generally  invade  either  of  them 
and  leave  the  other  unaffected. 

Treatment  of  Perimetritis: 

From  what  I  have  seen  and  had  to  do  with  these  affections,  I  am 
led  to  prescribe  in  a  general  way  the  same  treatment  for  both  of  them. 

In  the  early  days  of  an  attack  of  peritonitis  the  object  of  treatment 
should  be  to  abort  the  inflammation,  and,  when  this  is  impracticable, 
to  limit  its  extent.  We  can  seldom  accomplish  the  first  of  these  objects 
unless  we  see  the  patient  and  recognize  the  nature  of  the  attack  in  the 
very  beginning.  It  is  not  possible  to  declare  just  how  many  hours  or 
days  must  elapse  when  we  are  no  longer  justified  in  trjdng  to  arrest 


TEEATMENT    OF    PEEIMETEITIS.  465 

the  disease,  for  this  will  greatly  depend  upon  the  intensity,  but  we  may 
always  find  something  in  the  conditions  to  guide  us.  Before  any  con- 
siderable amount  of  effusion  and  tumefaction  has  taken  place  we  may 
hope  to  check  the  progress  of  the  inflammation,  even  if  this  is  two  or 
three  days  after  the  commencement,  or,  when  great  swelling  has 
occurred,  we  may  still  expect  to  limit  its  extent.  The  symptoms  indi- 
cating the  measures  necessary  to  interrupt  the  inflammation  are  great 
pain,  accompanied  by  tumefaction.  These  call  for  an  energetic  anti- 
phlogistic treatment  as  the  strength  of  the  patient  will  bear.  If  she  is 
robust,  from  twelve  to  twenty  leeches  on  the  hypogastrium  should  be 
applied  at  once,  and  after  they  have  fallen  off  the  hemorrhage  must 
be  encouraged  by  poultices  or  fomentations  until,  if  possible,  the  hard- 
ness of  the  pulse  is  affected.  At  the  same  time  a  large  dose  of  opium, 
or  one  of  its  preparations,  should  be  administered,  and  repeated  in 
such  quantities  as  to  keep  the  pain  in  complete  subjection,  and  not 
merely  given  from  time  to  time  when  the  pain  returns. 

If  the  patient  is  not  robust  we  cannot  resort  to  bloodletting,  but 
we  must  always  administer  the  opium  in  this  way.  As  secondary 
measures  the  arterial  sedatives  may  follow  the  depletion,  when  that 
is  deemed  advisable,  or  be  our  main  reliance  if  we  do  not  consider  it 
best  to  deplete.  Veratrum  viride  has  gained  such  a  reputation  that 
it  would  naturally  suggest  itself  as  the  most  efficient  of  these.  It 
may  be  given  in  doses  sufficient  to  control  the  circulation,  and  keep  it 
under  control  for  the  first  five  or  six  days  of  severe  attacks.  Poul- 
tices or  fomentations  to  the  hypogastric  region  should  be  one  of  the 
features  of  the  treatment  for  the  whole  of  the  more  active  stages  of 
the  disease.  They  will  often  give  marked  relief.  Large  injections 
of  very  warm  water,  the  patient  lying  on  her  back,  should  also  be 
employed.  An  apparatus  that  will  permit  the  water  to  run  off  with- 
out wetting  the  clothing  will  be  indispensable  to  the  proper  manage- 
ment of  the  injections.  This  kind  of  treatment  will  sometimes  check 
the  force  of  the  attack  in  a  very  short  time  by  arresting  or  limiting 
the  extent  of  the  inflammation,  and  thus  save  the  patient  from  the 
protracted  suffering  which  neglect  of  energetic  treatment  is  sure  to 
entail. 

After  the  effusion  has  taken  place,  and  before  the  period  of  sup- 
puration has  arrived,  alteratives,  such  as  mercury  and  iodide  of  potas- 
sium, are  very  important  remedies.  The  former  may  be  given  in  small 
and  frequently-repeated  doses,  until  the  slightest  possible  indication 
of  its  general  effects  are  noticed,  when  it  should  be  displaced  by  the 
iodide.  This  is  the  period  when  decided  saline  laxatives  are  useful 
and  advisable. 

When  the  symptoms  indicate  the  commencement  of  suppuration  we 
can  no  longer  continue  all  of  the  foregoing  treatment. 

•  30 


466  ACUTE    PERIMETRITIS. 

The  opiates  may  now  be  given  when  the  pain  requires  it.  Tlie  regi- 
men and  medication  should  be  changed  to  quinine  in  liberal  doses, 
two  to  four  grains  or  more,  as  often  as  necessary,  to  keep  up  its  influ- 
ence, and  supporting  food  in  as  large  quantities  and  such  quality  as 
the  stomach  and  rectum  will  bear. 

Unfortunately  we  are  often  called  upon  to  treat  patients  who  have 
already  passed  the  time  when  any  other  than  the  supporting  and 
anodyne  treatment  would  be  entirely  out  of  consideration,  because 
many  of  these  patients  have  been  too  greatly  reduced  by  preceding 
influences  to  permit  of  any  other  than  anodyne  and  s.upporting  treat- 
ment from  the  beginning.  These  are  the  unfortunates  who  linger  for 
weeks,  and  sometimes  for  months,  in  spite  of  anything  we  can  do  for 
them. 

During  the  progress  of  perimetritis  there  is  a  time  when  counter- 
irritation  will  be  of  great  service.  After  the  more  acute  symptoms 
have  subsided,  and  effusion  is  evident,  a  blister  applied  over  the  iliac 
region,  where  the  pain  is  greatest,  or  over  the  hy230gastrium,  if  that  is 
the  location  of  the  most  pain,  will  be  required. 

The  blister  applied  at  this  time  will  often  relieve  the  deep-seated 
pain,  prevent  the  effusion  from  becoming  purulent,  and  excite  the 
absorbents  to  remove  it. 

Later  in  the  disease  tincture  of  iodine  will  go  far  toward  accomplish- 
ing the  same  objects. 

A  question  arises  at  the  suppurative  stage  of  the  affection  which 
must  be  decided  after  a  careful  survey  of  the  whole  case,  viz.,  should 
we  evacuate  the  pus,  or  should  this  process  be  wholly  left  to  nature  ? 
As  one  of  the  disastrous  terminations  is  a  rupture  in  the  peritoneal 
cavity,  as  nature  often  selects  very  circuitous  and  unsatisfactory  via- 
ducts, as  the  rectum,  bladder,  etc.,  and  as  a  consequence  of  this  last 
circumstance  the  recovery  is  very  much  protracted,  I  think  we  should, 
when  practicable,  furnish  the  pus  an  outlet  of  our  own  choosing,  and 
as  early  as  can  be  conveniently  done.  Soon  as  evidences  of  suppu- 
ration begin  to  be  manifested  through  the  general  symptoms,  we 
should  make  as  thorough  an  examination  as  we  can  to  ascertain  where 
the  collection  has  occurred.  If  we  can  discover  the  pus,  we  evacuate 
without  apprehension  of  damage  to  any  of  the  organs.  If  our  first 
examination  fails  to  satisfy  us,  it  should  be  repeated  as  often  as  every 
twenty-four  hours  until  the  discovery  is  made.  When  this  is  done, 
we  institute  one  or  two  precautionary  measures,  which  will  almost 
preclude  the  possibility  of  doing  harm  by  an  intelligent  penetration. 
The  first  is  to  completely  evacuate  the  contents  of  the  bladder  and 
rectum  by  the  catheter  and  an  injection.  We  ought  to  be  sure  that 
the  rectum  is  empty  of  fluid  and  gas.  I  knew  fluid  in  the  rectum  to 
so  far  deceive  a  practitioner  as  to  cause  him  to  make  preparation  for 


TREATMENT   OF    PERIMETRITIS.  467 

its  puncture.  We  ought  to  pass  the  catheter  into  the  bladder  and 
rectum  after  we  sit  down  to  operate.  The  next  precautionary  measure 
is  to  introduce  the  exploring  trocar  into  the  tumor,  and  after  the  pus 
has  made  its  appearance,  open  the  cavity  by  the  side  of  the  retained 
canula.  In  this  way  I  think  there  is  great  safety  in  the  operation. 
The  patient  may  be  preiDared  for  the  puncture  by  being  placed  on 
the  left  side  before  a  good  light,  as  if  for  operation  for  vesico-vaginal 
fistula,  and  anaesthetized.  The  part  may  be  exposed  by  Sims's  specu- 
lum. The  instrument  most  convenient  for  making  the  incision  is  a 
tenotomy  knife.  The  opening  should  be  free  and  direct,  so  as  to 
permit  of  a  ready  discharge.  The  opening  should  not  be  allowed  to 
close.  This  may  be  prevented  by  keeping  a  tent  in  the  wound  until 
the  pus  ceases  to  be  discharged.  The  objects  of  thus  opening  the 
cavity  are  to  secure  an  external  and  safe  outlet  and  its  ready  evacua- 
tion, and  thereby  attain  a  speedy  cure  and  safety  against  peritoneal 
inflammation.  When  the  chronic  form  consists  in  frequent  repeti- 
tions of  the  inflammation,  on  account,  perhaps,  of  its  imperfect  sub- 
sidence, much  may  be  done  by  persistent  counter-irritation,  and 
among  the  best  kind  is  a  seton  in  the  groin  kept  running  for  months. 
An  issue  will  have  equal  good  effect.  This  permanent  form  of  counter- 
irritation  is  better,  I  think,  than  blistering  or  pustulation.  When  the 
opening  into  the  intestine  or  bladder  becomes  fistulous,  as  it  some- 
times does,  and  the  discharge  continues  for  months  and  even  years  if 
there  is  no  vaginal  opening,  and  the  discharge  is  into  the  bowel  or 
bladder,  we  should  seek  for  a  point  in  the  tumor  where  it  may  be 
punctured,  and  the  opening  made  free  and  direct  through  the  vagina. 
If  no  such  point  can  be  found,  we  cannot,  with  propriety,  interfere 
surgically.  The  openings  are,  however,  often  located  so  that  we  may 
easily  reach  them,  as  through  the  lower  part  of  the  abdominal  walls, 
the  labia,  the  gluteal  region,  the  perineum,  or  vagina.  If  the  Orifice 
is  accessible,  we  may  generally  succeed  in  obliterating  the  suppurating 
cavity  and  fistulous  canal.  Preparatory  to  making  an  effort  to  do  so, 
we  should  try  to  ascertain  the  tortuosities  of  the  fistulous  duct  and 
the  depth  of  the  pus-cavity.  In  some  instances  the  canal  is  so  crooked 
that  the  straight  probe  will  pass  but  a  very  short  distance,  and  it  be- 
comes necessary  to  send  it  in  various  ways ;  and  sometimes  an  elastic 
or  elm  bougie  will  suit  better  for  a  probe  than  the  ordinary  metallic 
one.  Professor  Simpson  recommends  leaving  a  wire  in  the  track  of 
the  fistula  until  adhesive  inflammation  is  excited.  I  have  not  tried 
this  means,  for  I  have  been  so  well  pleased  with  injections  of  car- 
bolized  water  that  I  have  used  them  almost  exclusively.  I  inject 
through  a  small-sized  catheter.  The  smallest-sized  elastic  catheter, 
pushed  to  the  bottom  of  the  cavity,  will  convey  the  fluid  in  its  con- 
centrated strength  to  the  bottom,  and  thus  produce  the  eff'ect  at  that 


468  ■  ACUTE   PERIMETEITIS. 

point.  We  ought,  after  introducing  the  catheter,  to  inject  the  cavity 
with  tejDid  soapsuds,  so  as  completely  to  cleanse  the  internal  parts  of 
pus,  and  then  immediately  introduce  the  solution. 

Sometimes  the  first  injection  prevents  the  production  of  pus  and 
causes  adhesive  inflammation.  In  order  effectually  to  inaugurate  the 
treatment,  it  generally  becomes  necessary  to  slit  up  the  orifice  of  the 
fistula  somewhat,  as  it  is  usually  smaller  than  any  other  part  of  the 
duct. 


CHAPTER    XXVII. 

CHEONIC  PERIMETRITIS. 

Chronic  perimetritis  is  a  common  form  of  disease.  It  is  the 
cause  of  much  suffering  and  is  often  misunderstood. 

Causes. 

By  far  the  greater  number  of  cases  can  be  traced  to  the  acute  form, 
but  there  is  no  doubt  that  many  others  have  an  entirely  different 
origin. 

Most  practitioners  of  extensive  observation  must  have  seen  many 
cases  of  chronic  perimetritis,  in  the  history  of  which  no  evidence 
could  be  found  that  the  patient  had  ever  had  an  acute  attack. 

We  know  that  the  acute  form  is  often  the  result  of  an  extension  of 
inflammation  from  the  uterus  and  vagina  to  the  broad  ligament  and 
peritoneum,  and  I  think  I  have  seen  instances  where  inflammation 
of  a, moderate  grade  had  been  propagated  from  the  uterus  and  re- 
mained thus  associated  for  an  indefinite  length  of  time. 
,  This  I  think  is  the  right  way  to  account  for  those  cases  so  fre- 
quently found  complicating  chronic  uterine  diseases,  and  in  which 
the  symptoms  of  perimetritis  are  completely,  masked  by  those  attend- 
ing the  more  prominent  affection. 

It  is  indeed  very  seldom  either  in  the  acute  or  chronic  form  that  it 
is  not  accompanied  by  inflammation  of  the  uterus,  and  it  is  equally 
rare  that  the  disease  is  not  propagated  from  the  uterus  or  vagina. 

In  very  few  cases  it  is  reasonable  to  suppose  that  the  inflammation 
may  originate  in  the  ovaries. 

I  do  not  hesitate  to  assert,  however,  that  I  have  not  seen  many  cases 
of  acute  or  chronic  perimetritis, — where  their  history  could  be  clearly 
traced, — that  were  not  secondary  in  their  origin  and  transmitted  from 
the  uterus. 

Varieties. 

Chronic  perimetritis  presents  quite  a  variety  of  appearances ;  one 
form  traceable  directly  to  the  acute  attack  is  chronic  abscess. 

After  the  process  of  suppuration  has  led  to  a  discharge  of  pus,  and 
the  acute  symptoms  have  subsided,  the  patient  still  suffers  from  ten- 
derness, pain,  and  long-continued  suppuration.  The  pyogenic  cavity 
is  perpetuated  by  the  imperfect  discharge  of  pus.  While  the  pus  is 
being  constantly  discharged,  the  sac  whence  it  comes  is  not  entirely 
emptied,  and  there  is  enough  pus  generated  to  keep  up  a  perpetual 


470  CHROXIC   PEEIMETEITLS. 

drain.  The  manner  in  wliicli  the  original  opening  Tras  effected  is 
almost  always  the  cause  of  this  imperfect  evacuation  of  the  abscess. 
The  canal  or  conduit  leading  from  the  cavity  is  tortuous,  and  pene- 
trates the  muscular  fibres  of  the  rectum  or  bladder  diagonally,  so  as 
to  form  a  valvular  opening.  The  pus,  after  having  travelled  along 
between  the  different  muscular  layers  of  the  walls  of  one  of  these 
organs,  makes  an  opening  that  is  closed  with  every  contraction  and 
opened  with  each  relaxation  of  the  fibres.  Still  another  unfortunate 
method  of  perforating  the  intestinal  tube  or  bladder  is  when  the  level 
of  the  sac  is  below  the  opening.  In  all  of  these  ways  the  complete 
evacuation  may  be  prevented  and  the  discharge  protracted  for  years. 
We  meet  with  another  form  of  perimetritis  in  which  the  abscess  seems 
to  have  been  cured  after  complete  evacuation.  The  subsidence  of  the 
symptoms  is  so  complete  as  to  leave  the  patient  in  the  enjoyment  of 
fair  health.  After  a  time,  of  greater  or  less  duration,  sometimes  a  few 
weeks  only,  at  others  several  months,  the  symptoms  recur  in  a  less 
severe  degree  than  in  the  acute  form,  and  after  a  duration  of  several 
days  or  weeks  a  discharge  of  pus  is  again  succeeded  by  relief 

These  attacks  are  repeated  an  indefinite  number  of  times,  and  if  the 
patient  recovers  it  is  after  a  number  of  months  or  years. 

The  suffering  is  sometimes  very  great  and  followed  by  large  dis- 
charges. More  frequently,  however,  the  pain  is  not  so  excruciating 
and  the  discharge  of  pus  is  small. 

Again,  other  cases  are  met  with  in  which  the  progress  of  the  in- 
flammation from  the  beginning  is  very  slow,  and  not  attended  with 
very  severe  pain,  but  continues  until  quite  a  large  amount  of  pus  is 
formed,  which  remains  in  the  sac,  with  very  little  tendency  to  ulcerate 
through  the  tissue.  Whether  the  pus  in  some  of  these  cases  would 
ever  be  discharged  by  spontaneous  processes  is  a  matter  of  great  un- 
certainty. I  have  seen  cases  where  from  the  history  I  felt  assured 
that  this  indolent  abscess  had  existed  for  years. 

I  saw  a  case  in  this  city  with  Dr.  T.  D.  Fitch,  that  he  informed  me 
had  been  in  the  condition  it  was  when  I  saw  it  for  three  years.  That 
he  had  seen  it,  discovered  pus,  and  advised  its  evacuation,  as  long  as 
that,  before  I  was  called.  I  have  seen  others  equally  protracted  in 
my  own  practice  and  in  consultation. 

Some  cases  are  met  with,  the  history  of  which  includes  a  number 
of  recurring  acute  or  subacute  non-suppurating  attacks,  weeks  or 
months  apart,  that  finally  culminate  in  suppuration.  Patients  suf- 
fering from  this  form  have  an  attack  of  fever,  with  pain  in  the  pelvis, 
pains  running  down  the  limbs,  tenderness,  and  perhaps  very  slight 
tumefaction  of  the  h^'pogastric  region.  This  passes  for  "inflamma- 
tion of  the  bowels."  The  patient  more  or  less  completely  recovers 
from  the  attack,  and  after  a  time  is  again  prostrated  with  similar  but 
less  pronounced  symptoms,  these  run   a  course  of  four  or  six  weeks 


SYMPTOMS    AND    DIAGNOSIS.  471 

and  the  patient  again  recovers.  This  time  the  fever  may  be  called 
typhoid  or  bilious  fever;  in  a  subsequent  attack  suppuration  reveals 
the  true  character  of  the  disease.  The  explanation  of  all  these  symp- 
toms is  that  the  patient  had  several  attacks  of  moderate  perimetritis, 
that  for  want  of  proper  physical  examination  were  misunderstood 
and  called  by  different  names. 

But  all  cases  do  not  end  in  suppuration.  The  exudate  does  not 
break  down,  but  continues  hard,  and  is  formed  in  masses  of  greater  or 
less  size  in  the  broad  ligament,  attached  to  the  side  of  the  uterus,  or 
between  the  uterus  and  bladder.  Or  where  the  disease  is  in  the  peri- 
toneum the  exudation  may  be  above  the  brim  of  the  pelvis  in  the  iliac 
region.  These  deposits  of  fibrin  are  often  mistaken  for  tumors.  Not 
unfrequently  a  large  part  of  one  side  of  the  pelvis  is  filled  with  a  hard 
immovable  mass  of  plastic  effusion,  and  the  uterus  misplaced  and 
fixed  in  its  malposition.  In  other  instances  the  accumulation  is  small 
and  does  not  affect  the  position  or  mobility  of  that  organ. 

Instead  of  the  localized  effusions  here  described,  sometimes  there 
is  a  diffuse  moderate  infiltration  of  fibrin  in  the  cellular  tissue  that 
causes  thickening  of  the  ligament.  The  j^arts  are  less  elastic  than 
usual,  the  uterus  less  movable  yet  not  fixed. 

This  condition  is  the  one  most  frequently  present  when  the  uterus 
is  said  to  be  "bound  down,"  so  that  it  cannot  be  reposited  and  re- 
tained in  position  without  causing  great  suffering  or  awaking  acute 
inflammation. 

There  is  also  a  very  moderate  degree  of  chronic  inflammation — 
hyperffimia  with  sensitiveness — which  invades  and  remains  in  the  peri- 
metric tissue  without  causing  effusion  or  any  considerable  degree  of 
tumefaction. 

Whether  this  degree  or  form  of  disease  is  one  introductory  or  pre- 
paratory to  the  more  grave  acute  grade,  or  one  that  may  last  indefi- 
nitely, without  any  great  variation  in  intensity,  is  not  certain.  It  is 
probably  the  condition  to  which  the  term — so  frequently  used — 
"latent  inflammation"  is  applied,  because  under  certain  favoring 
circumstances  the  vascular  and  nervous  action  is  developed  into  the 
acute  form. 

I  have  no  doubt  that  this  low  degree  of  inflammation  may  exist  a 
long  time,  and  perhaps  indefinitely,  in  the  absence  of  causes  exciting 
it  to  a  higher  grade  of  action. 

Symptoms  and  Diagnosis. 

Generally  the  symptoms  of  chronic  perimetritis  are  not  distinctive, 
and  arrange  themselves  under  the  general  head  of  "  Uterine  Symp- 
toms." In  those  cases  in  which  pus  is  formed  the  symptoms  become 
more  marked,  and  we  may  not  be  at  a  loss  to  understand  them ;  but 


472  CHRONIC   PERIMETRITIS. 

even  in  some  of  these  the  symptoms  are  not  decisive.  We  must,  for 
the  most  part,  therefore,  deiDend  upon  physical  examination.  The 
history  of  those  cases  of  frequently  recurring  paroxysms  of  pelvic 
inflammation,  which  for  many  months,  or  even  3'ears,  precede  sup- 
puration, will  often  indicate  pretty  clearly  the  character  of  the  disease 
with  which  we  have  to  deal.  Yet,  without  an  examination  of  the 
pelvic  organs,  even  these  cannot  be  diagnosed  until  they  have  about 
run  their  course. 

There  is  generally  one  element  which,  to  one  whose  attention  is 
attracted  in  that  direction,  will  be  found  to  be  almost  always  present, 
viz.,  fever  in  a  more  or  less  marked  degree.  In  all  but  the  indolent 
abscess,  and  the  slighter  degree  of  its  form,  in  which  there  is  no  exu- 
dation, this  symptom  will  pretty  uniformly  present  itself. 

Physical  examination  will  uniformly  develop  sensitiveness.  It  will 
often  happen  that,  during  the  examination,  the  tenderness  will  be  so 
slight  as  not  to  elicit  complaint  from  the  patient ;  but,  after  the  mani- 
pulation is  ended,  there  will  be  left  aching  and  a  sense  of  tenderness. 
Sometimes  the  reaction  will  be  quite  severe  and  last  for  hours,  or  even 
awaken  an  acute  attach.  This  subsequent  tenderness,  however  slight, 
is  a  symptom  of  much  significance,  and  should  teach  caution  in  future 
examinations. 

Another  important  sign  (yet  not  so  important  as  the  last)  is  certain 
positions  of  the  uterus.  When  the  cervix  is  drawn  strongly  to  one 
side,  and  especially  if  it  is  fixed  in  that  position,  it  indicates  an 
irregularity  in  the  length  of  the  broad  ligament.  The  ligament  of  the 
side  toward  which  the  traction  is  noticed  is  shortened,  and,  while  not 
invariably  so,  the  shortening  is  frequently  owing  to  previous  or  present 
inflammation  in  the  connective  tissue  of  the  ligament.  If  associated 
with  tenderness  this  condition  ought  to  complete  the  diagnosis. 

Bimanual  examination  of  the  sides  of  the  pelvis  will  generally 
enable  us  to  detect  even  a  small  amount  of  fibrinous  deposits.  They 
may  generally  be  diagnosed  from  tumors  by  their  tenderness,  fixed- 
ness, and  loca]it3^  In  most  cases  they  will  be  fixed  to  the  i^elvic 
walls,  especially  when  situated,  as  most  of  them  are,  in  the  connective 
tissue  of  the  broad  ligament.  Sometimes,  however,  they  are  developed 
at  the  side  of  the  uterus,  and  adhere  firmly  to  it.  In  such  cases  they 
move  with  the  uterus,  and  cannot  be  made  to  move  upon  that  organ. 
These  are  more  likely  to  be  mistaken  for  subserous  fibrous  tumors. 
The  history  will  do  something  toward  clearing  up  the  diagnosis.  There 
will  always  be  a  history  of  inflammation.  The  menses  are  not  so  likely 
to  be  profuse  as  in  the  case  of  fibrous  tumors.  Each  manipulation 
will  be  attended  or  succeeded  by  tenderness.  When  the  deposit  is 
extensive  the  position  of  the  uterus  is  generally  affected  b}'  it  also. 
The  indurated  patches  at  the  brim  of  the  pelvis,  left  by  local  perito- 
nitis, are  sometimes  mistaken  for  tumors.     We  should  give  due  weight 


TEEAT.MEXT.  473 

to  the  history  of  inflammation,  with  which  these  are  connected,  and 
the  tenderness  that  is  developed  by  pressure  and  other  manipulations. 
When  examining  them  we  will  generally  find  them  flat  instead  of 
globular,  and  not  movable.  But  the  most  remarkable,  and,  I  think, 
pathognomonic  sign,  is  resonance  under  percussion.  However  exten- 
sive these  indurated  masses  may  be,  percussion  will  elicit  intestinal 
resonance  over  the  whole  space  occupied  by  them.  The  resonance  is 
clue  to  the  fact  that  the  effused  fibrin  surrounds,  instead  of  displaces, 
the  intestine,  and  in  coagulating  includes  that  tube  in  the  indurated 
mass.  These  signs  are  all  different  from  those  evinced  by  an  exami- 
nation of  a  tumor.  The  signs  of  the  indolent  abscess  of  the  broad 
ligament  are  an  immovable  tumor,  which  is  elastic  or  fluctuating, 
and  the  test  is  aspiration. 

Treatment. 

The  treatment  of  these  several  diverse  conditions  must  necessarily 
vary.  The  form  in  which  sensitiveness  and  hyperemia  are  not 
attended  with  effusion  will  require  great  circumspection  in  the  treat- 
ment.* 

One  is  continually  tempted  by  local  inconvenience  to  depend  too 
much  upon  stimulating  local  treatment,  whereas  I  think  it  is  benefited 
less  by  local  measures  than  any  other  form  of  the  disease.  It  is,  in 
fact,  more  frequently  connected  with,  if  not  dependent  upon,  some 
dyscrasia  (or  dysthetica)  than  upon  local  conditions,  and  hence  must 
be  treated  largely  by  general  measures.  One  of  the  most  efficacious 
of  these  measures  is  a  judicious  change  of  climate  and  habits.  The 
object  in  making  a  change  of  climate  and  habits  should  be  to  revolu- 
tionize the  circumstances  of  the  patient.  It  is  astonishing  how  these 
patients,  who  cannot  stand  upon  their  feet,  on  account  of  the  great 
sensitiveness  of  the  pelvic  organs,  will  improve  on  a  long  journey, 
which,  from  the  symptoms,  would  seem  impracticable.  A  trip  to,  and 
residence  in,  California  has  done  more  to  cure  some  of  these  patients 
than  could  have  been  done  by  medicine  alone.  But  much  good  can 
be  done  by  medicines,  such  as  will  improve  the  condition  of  the  sys- 
tem. The  bowels  should  be  the  subject  of  special  care.  They  will 
more  frequently  than  otherwise  be  constipated,  and  their  secretions 
inferior  in  quality  as  well  as  scarce  in  quantity.  The  mercurials  and 
bitter  tonics,  if  perseveringly  administered,  will  often  correct  the  con- 
stipation, improve  digestion,  and  act  favorably  on  the  depraved  state 
of  the  general  system. 

The  sixteenth  of  a  grain  of  the  bichloride  of  mercury,  with  a  full 
dose  of  the  compound  tincture  of  cinchona,  or  the  tincture  of  Colombo, 
three  times  a  day,  makes  an  excellent  mixture  for  such  cases.  The 
diet  should  be  full  in  quantity  and  nourishing  in  quality.  Exposure 
to  the  fresh  air  and  sunshine  is  also  indispensable  to  restoration.     The 


474  CHRONIC    PERIMETRITIS. 

exercise  should  not  be  too  much  restricted,  because  confinement 
always  aggravates  the  general  condition,  and  moderate  exercise  is  not 
harmful  to  the  local  trouble.  The  special  treatment  should  consist 
in  large  injections  of  tepid  water,  and  extensive  but  very  moderate 
counter-irritation. 

The  counter-irritant  I  rely  upon  most  is  the  tincture  of  iodine, 
diluted  with  an  equal  quantity  of  alcohol.  This  liniment  should  be 
applied  over  the  whole  lower  part  of  the  abdomen,  back,  and  hips.  I 
believe,  however,  that  the  local  treatment  can  often  be  dispensed  with 
if  judicious  management  of  the  general  health  is  persevered  in  and 
diligently  applied. 

In  the  cases  in  which  fibrinous  deposits  are  observed,  special  treat- 
ment is  of  more  importance.  And  the  first  thing  that  I  would  insist 
upon  is  that  pessaries  and  stimulating  applications  to  the  uterus  should 
be  abjured. 

Large  hot  or  tepid  water  injections  and  sitz-baths  will  be  of  great 
service.  It  will  sometimes  be  found  that  hot- water  injections  will 
cause  discomfort,  while  tepid  water  will  be  followed  by  relief,  and  the 
effect  experienced  from  them  should  guide  us  in  our  choice. 

Concentrated  counter-irritants  in  the  inguinal  regions  will  also  be 
found  very  beneficial.  A  small  seton  I  believe  to  be  the  best  form  of 
counter-irritant,  and  when  kept  clean  and  shielded  from  the  friction 
of  the  clothing  it  will  give  the  patient  but  little  inconvenience.  We 
must  not  forget  the  soothing  influence  of  glycerin  tampons. 

Diligent  attention  to  the  general  health  is  of  the  greatest  importance 
also,  and  very  small  doses  of  mercury,  laxative  diet,  and  exposure  to 
pure  air  in  a  mild  climate  will  generally  suffice.  In  the  suppurative 
variety,  which  is  but  the  advanced  stage  of  the  latter  form,  attention 
to  the  general  health  is  of  paramount  importance.  When  the  suppu- 
ration is  intermitted  with  intervals  of  comparative  comfort,  we  may 
generally  interrupt  the  paroxysm  by  establishing  and  keeping  up  for 
a  considerable  period  a  discharge  from  the  iliac  or  inguinal  region 
over  the  seat  whence  the  discharge  emanates.  I  know  of  no  one  remedy 
that  does  so  much  good  as  the  seton.  It  should  be  larger  than  in  the 
last  variety,  and  the  local  irritation  kept  up  for  several  weeks  or  even 
months. 

When  the  suppuration  is  continuous,  in  addition  to  attending  to  the 
general  health,  we  should  try  to  establish  a  more  direct  outlet.  When 
the  discharge  is  from  the  rectum  we  may  sometimes  pass  a  bent  probe 
through  the  opening  and  bring  its  point  down  upon  the  roof  or  side 
of  the  vagina,  and  make  it  a  guide  to  a  puncture  in  that  direction. 
When  we  cannot  improve  the  direction  of  the  outlet  we  may  sometimes 
destroy  the  pyogenic  character  of  the  cavity  by  injections  of  carbo- 
lized  water  through  a  flexible  catheter,  introduced  and  carried  to  the 
bottom  of  the  cavitv. 


TREATMENT.  475 

How  to  treat  chronic  pelvic  abscess  in  all  its  phases  is  one  of  the 
most  difficult  problems  in  gynecological  surgery.  The  plain  proposi- 
tion to  evacuate  the  pus  and  maintain  a  free  opening  expresses  the 
main  objects  to  be  accomplished.  The  difficulty  consists  in  selecting 
the  best  method  of  doing  so  in  all  cases.  Of  course  this  will  vary  with 
the  differences  noticed  in  each  case.  A  rule  which  is,  I  think,  a  good 
guide,  is  to  open  the  abscess  through  the  nearest  surface.  If  nearest  to 
the  vagina  it  should  be  opened  into  that  cavity,  if  near  the  rectum, 
into  the  rectum.  Sometimes  the  pus  makes  its  way  to  the  cutaneous 
surface  and  then  it  must  be  evacuated  at  the  point  it  approaches.  We 
will  seldom  be  able  to  divert  the  pus  from  the  course  it  takes  in  making 
its  way  out.  When  practicable  the  opening  should  be  at  the  lowest  pus 
level  and  when  we  can  choose  the  most  favorable  time  and  locality  for 
the  evacuation,  the  results  will  be  satisfactory,  both  as  to  the  primary 
and  continued  evacuation. 

Perplexities  are  now  frequently  met  with  when  the  abscess  has  dis- 
charged spontaneously  in  some  unsuitable  place  and  in  such  a  manner 
as  to  prevent  a  complete  discharge.  In  cases  where  suppuration  takes 
place  near  the  vagina,  and  the  pus  finds  its  way  into  that  cavity  it 
is  generally  easy  to  correct  any  defective  manner  in  the  discharge 
by  enlarging  and  keeping  the  opening  patent  until  the  cavity  is  ob- 
literated. 

If  there  is  any  difficulty  in  finding  the  opening,  or  in  the  manipula- 
tion for  its  enlargement,  the  vagina  may  be  stretched  and  dilated  suf- 
ficiently to  give  freedom  in  our  operations.  This  will  often  greatly 
facilitate  our  efi"orts  and  thus  insure  the  best  results.  For  this  purpose 
we  may  use  Sims's  or  Simon's  speculum,  or  we  may  employ  our  thumbs 
as  for  dilating  the  rectum.  The  enlargement  of  the  opening  to  the 
abscess  should  be  effected  by  stretching  and  tearing  rather  than  cut- 
ting. Thus  we  will  risk  but  little  from  hemorrhage.  The  dilatation 
can  be  done  by  a  small  bladed  uterine  dilator  and  the  finger,  or  by 
Hanks'  rubber  dilator  succeeded  by  the  finger.  After  thus  dilating 
the  opening  the  whole  interior  of  the  cavity  should  be  scraped  by  the- 
finger  or  dull  wire  curette,  for  it  will  generally  be  found  that  the  inner 
surface  of  the  chronic  suppurating  cavity  is  covered  with  large,  irregu- 
lar and  indolent  granulations.  These  should  be  thoroughly  removed. 
The  cavity  ought  be  washed  out  daily  with  plenty  of  pure  warm  water.. 
Sometimes  there  is  a  tendency  in  the  discharging  orifice  to  contract 
and  close  up.  This  may  be  counteracted  by  repeating  the  dilatations 
with  the  finger  as  often  as  necessary. 

If  the  suppurating  cavity  has  discharged  into  the  rectum,  and  the 
evacuation  is  unsatisfactory,  and  draws  out  a  tedious  and  chronic 
course,  the  treatment  should  be  the  same  as  directed  for  the  vagina.. 
The  rectum  must  be  dilated  by  the  thumbs  to  the  greatest  extent.. 
When  this  is  sufficiently  done  the  whole  rectal  cavity  maybe  brought. 


476  CHEONIC   PERIMETEITIS. 

within  reach  and  view  by  retractors  and  we  can  with  great  facility  and 
safety  operate  within  it.  I  have  on  more  than  one  occasion  reached 
the  discharging  orifice  of  an  abscess  at  the  brim  of  the  pelvis.  After 
the  exposure  of  the  discharging  orifice  the  treatment  is  the  same  as  in 
the  vagina. 

In  speaking  of  my  treatment  of  abscess  of  the  pelvis  some  of  my 
friends  have  misunderstood  and  misinterpreted  me.  I  have  been 
understood  as  advising  the  use  of  cutting  instruments  in  enlarging  the 
opening.  I  mention  this  with  a  view  to  correct  this  impression.  I  have 
thus  far  only  attempted  the  enlargement  of  the  inadequate  oj)ening 
already  existing  with  instruments  that  would  not  cut,  and  as  much  as 
possible  with  the  finger.  This  plan  has  been  objected  to  through  fear 
of  hemorrhage ;  but  following  the  directions  here  given  there  is  no 
more  danger  than  operating  through  the  vagina.  And  it  will  be  ap- 
parent to  any  one  doing  this  operation  that  if  a  vessel  were  wounded 
the  ligation  of  it  would  be  not  at  all  difficult. 

The  cavities  of  most  chronic  abscesses  of  the  j)elvis  are  not  simple 
and  uniform  in  shape,  but  often  present  subdivisions  with  partitions 
and  projections  from  their  surfaces,  more  or  less  comj)letely  dividing 
them  into  compartments.  These  should  be  broken  down  by  the 
finger  in  order  to  permit  the  free  flow  of  pus  from  every  part.  Some- 
times the  level  of  the  pus-cavity  is  lower  than  the  orifice  through 
which  it  escapes.  In  that  case  the  elevated  septum  between  the  rec- 
tum and  the  suppurating  cavity  should  be  torn  down  by  the  finger  to 
a  level  with  the  bottom  of  the  purulent  cavity.  Again  I  can  assure 
the  reader  that  when  this  is  carefully  clone  there  is  no  danger  from 
bleeding  and  that  any  severed  vessels  may  be  secured  without  diffi- 
culty. 

The  important  points  in  this  method  of  evacuating  the  pus  from  a 
pelvic  abscess  through  the  rectum  are :  First,  to  stretch  the  sphincter 
until  the  whole  interior  of  the  rectum  is  brought  to  light.  Second,  to 
tear  the  old  opening  of  the  abscess  so  largely  as  to  admit  the  easy  in- 
troduction of  the  fingers.  Third,  to  reduce  the  irregularities  of  the 
cavity  by  tearing  them  away.  Fourth,  to  reduce  the  septum  dividing 
the  abscess  from  the  rectum  to  a  level  with  the  bottom  of  the  pyogenic 
cavity.  Fifth,  to  scrape  away  by  means  of  the  finger  or  dull  curette 
the  granular  projection  from  the  wall  of  the  cavity. 

As  in  the  case  of  the  evacuation  from  the  vagina,  the  rectum  may 
require  dilating  again,  as  it  will  also  be  necessary  sometimes  to  repeat 
the  stretching  of  the  opening  to  the  pus-cavity. 

There  are  undoubtedly  instances  very  high  up — partly  abdominal 
— from  which  the  pus  cannot  be  evacuated  according  to  the  plan  I 
have  directed.  In  these  laparotomy  is  advisable,  in  fact,  demanded, 
as  the  only  method  of  reaching  the  cavity.     I  am  sure,  however,  such 


TREATMENT.  477 

cases  are  rare.  Mr.  Tait,  if  I  understand  him  rightly,  and  others, 
prefer  laparotomy  and  drainage  above  the  pelvis  to  the  operation 
through  the  rectum.  I  have  not  done  laparotomy  for  pelvic  abscess 
except  where  connected  with  the  tubes,  but  I  have  had  the  oppor- 
tunity of  seeing  the  results  of  four  cases,  and  have  witnessed  two  oper- 
ations. I  was  strongly  impressed  with  the  difficulties  and  dangers  of 
this  very  formidable  procedure  as  compared  to  those  of  the  operation 
through  the  rectum. 

In  laparotomy  for  pelvic  abscess  the  incision  should  be  low  down 
in  the  median  line,  or  what  in  some  cases  is  better,  over  the  upper 
part  of  the  abscess,  near  the  line  of  the  pelvis  or  Poupart's  ligament  if 
on  the  sides.  When  the  abscess  is  exposed  the  edges  of  the  incision 
should  be  stitched  upon  it,  so  that  there  may  be  room  enough  for  the 
evacuation  between  them  without  danger  of  the  pus  finding  its  way 
into  the  peritoneal  cavity.  When  the  opening  is  made  through  which 
the  pus  escapes,  the  peritoneal  cavity  may  be  thoroughly  washed  out 
and  a  drainage-tube  inserted.  The  wound  may  then  be  dressed  anti- 
septically  and  treated  as  wounds  in  the  abdominal  walls  for  other  pur- 
poses. 

The  difference  as  to  the  dangers  and  difficulties  of  performance 
between  laparotomy  and  the  operation  through  the  rectum  are  so 
great  that  I  cannot  recommend  the  former  except  as  a  last  resort,  and 
after  the  latter  oj)eration  has  failed. 

We  occasionally  meet  with  a  collection  of  pus  at  the  superior  strait 
extending  into  the  pelvis  and  sometimes  attaining  very  imperfect 
evacuation  through  the  rectum.  This  may  be  incised  and  evacuated 
without  opening  the  peritoneal  cavity,  and  drained  with  very  little 
danger. 

Before  leaving  the  subject  I  will  mention  another  objection  urged 
against  the  operation  of  enlarging  the  opening  of  an  abscess  through 
the  rectum,  viz.,  the  danger  of  the  fseces  making  their  way  into  the 
cavity  and  producing  irritation.  This  objection  will  not  be  seriously 
entertained  when  it  is  remembered  that  the  sphincter  is  rendered  pow- 
erless to  retain  the  contents  of  the  rectum  and  that  the  abscess-cavity  is 
so  shaped  by  the  operation  that  the  fseces  would  not  be  retained.  Then 
it  should  be  further  remembered  that  healthy  fasces  are  not  irritating  to 
the  inside  of  these  cavities,  and  that  the  cavity  is  to  be  thoroughly 
washed  out  once  or  oftener  every  day.  Another  thing  about  which  I 
wish  to  be  a  little  more  explicit  is  that  of  the  opening  of  an  abscess 
in  the  rectum.  From  considerable  observation  I  am  convinced  that 
there  is  no  more  danger  in  opening  an  abscess  through  the  rectum 
than  through  the  vagina.  The  way  I  have  lately  operated  is,  after 
stretching  the  rectum  so  as  to  see  and  feel  the  place  where  the  pus  is 
located,  to  insert  the  point  of  a  scissors  with  the  blades  closed  and 


478  CHRONIC   PERIMETRITIS. 

follow  with  the  point  of  Hanks'  rubber  dilator.  The  dilator  may  be 
made  to  cause  quite  an  opening,  but  this  may  be  enlarged  by  the 
finger  or  other  instrument.  There  will  be  no  hemorrhage  if  the  opera- 
tion is  done  without  cutting. 

In  the  case  of  the  indolent  abscess  all  that  will  generally  be  found 
necessary  is  to  draw  off  the  pus  by  the  aspirator.  In  this  variety  the 
lining-membrane  (or  wall)  of  the  cavity  has  ceased  to  produce  pus, 
and  consequently  when  the  sac  is  emptied  the  fluid  does  not  reaccu- 
mulate.     I  have  seen  several  cases  thus  happily  terminated. 


CHAPTER   XXVII  I. 

DISPLACEMENTS  OF  THE  VAGINA,  BLADDEK,  AND  RECTUM. 

In  every  displacement  of  the  uterus  the  dh'ection  of  the  axis  and 
the  calibre  of  different  j)arts,  or  the  whole  of  the  vaginal  canal,  are 
changed  from  their  normal  conditions.  In  procidentia  the  vagina  is 
in  part  or  wholly  inverted.  In  such  cases,  however,  the  changes  are 
complications  of  the  displacements  of  the  uterus,  and  are  described 
and  treated  as  such. 

The  more  common  and  yet  not  entirely  independent  displacements 
of  the  vagina  are  knoAvn  as  cystocele  and  rectocele. 

Urethrocele^  Cystocele. 

Cystocele  is  a  prolapse  of  the  anterior  wall  of  the  vagina,  the  latter 
being  borne  down  by  a  prolapsed  bladder,  or  drawing  down  that 
organ  with  it.  The  prolapses  of  the  anterior  vaginal  wall  and  bladder 
may  also  make  sufficient  traction  upon  the  uterus  to  cause  prolapse 
of  that  viscus,  and  thus  be  complicated  by  it  without  the  posterior 
wall  of  the  vagina  being  much  disturbed.  Sometimes  the  mucous 
membrane  of  the  anterior  or  posterior  wall  of  the  vagina  may  prolapse 
through  the  vulva  without  displacing  the  fibrous  sheath,  the  bladder, 
or  the  rectum.  At  other  times  the  urethra  alone  will  descend  with 
the  vaginal  wall. 

Rectocele. 

When  the  posterior  wall  of  the  vagina  protrudes  externally  it  is 
generally,  in  nuUipars,  attended  with  displacement  of  the  anterior  wall 
of  the  rectum,  and  sometimes  the  uterus  is  drawn  down  and  displaced 
by  traction  of  the  wall  of  the  vagina.  In  nullipars  the  rectum  is 
usually  but  slightly  displaced. 

Symptoms. 

The  symptoms  of  cystocele  are  dragging  sensation  or  weight  in  the 
vagina,  with  leucorrhoea  and  burning  pain,  occasioned  by  the  inflam- 
mation from  the  exposure  or  friction  of  the  mucous  membrane  of  the 
vagina,  and  vesical  suffering.  In  recent  cases  there  is  simply  frequent 
desire  to  micturate  and  unsatisfactory  discharge  of  the  urine. 

As  the  case  becomes  chronic  the  incomplete  discharge  of  urine  leads 
to  its  decomposition,  the  precipitation  of  the  salts  contained  in  it,  and 
the  evolution  of  ammonia. 


480      DISPLACEMENTS    OF    THE    VAGIxNTA,   BLADDER,    AND    RECTUM. 

The  ammonia  and  salts  irritate  the  mucous  membrane  of  the  blad- 
der to  a  greater  or  less  degree,  and  in  aggravated  cases  severe  inflam- 
mation and  ulceration  occur,  attended  with  discharge  of  mucus,  blood, 
and  fetid  gases. 

These  local  results  are  attended  by  constitutional  disturbances  com- 
mensurate with  their  gravity. 

The  sufferings  in  rectocele  are  usually  less  severe.  There  is  weight, 
leucorrhoea,  and  unsatisfactory  defecation.  The  muscular  coat  of  the 
rectum  loses  its  tone  and  permits  the  fseces  to  collect  in  a  large  mass 
in  it,  which  intrudes  into  and  fills  up  the  vagina. 

When  an  effort  is  made  to  expel  the  excrement  it  is  apt  to  collect 
in  larger  quantities  and  remains  in  this  passive  pouch  until  the 
patient  presses  or  scoojds  it  out  with  her  fingers. 

Diagnosis. 

Upon  examining  the  vagina  the  anterior  or  posterior  prolapse  will 
be  readily  discovered,  and  may  be  isolated  by  passing  the  finger  into 
the  vagina.  If  the  anterior  wall  is  prolapsed  the  finger  will  2:)ass  be- 
hind the  tumor,  and  in  front  of  the  tumor  if  the  posterior  wall  is  the 
portion  affected. 

We  may  demonstrate  a  cystocele  by  introducing  the  catheter.  The 
instrument,  instead  of  passing  backward  and  upward,  will  go  down- 
ward and  backward,  and  the  point  may  be  felt  occupying  the  tumor. 
In  rectocele,  if  we  introduce  the  finger  into  the  rectum,  it  may  be 
turned  forward  toward  the  vagina  and  made  to  enter  the  tumor.  If 
the  prolapse  consists  of  the  mucous  membrane  alone,  the  finger  or 
catheter  will  not  pass  into  the  tum  or.  (See  Palpation  of  the  Pubo- 
vesico-uterine  Lig.,  p.  86,  also  Palpation  of  Vagina,  p.  88,  Chapter  II.) 

Causes. 

Loss  of  substance  or  tone  in  the  perineum  is  one  of  the  most  im- 
portant conditions  necessary  to  prolapse  of  the  vagina.  (See  Chapter 
VII.)  There  may  be  loss  of  substance  in  the  anterior  border  of  that 
body  from  rupture,  or  loss  of  firmness  from  subinvolution,  lack  of 
general  muscular  vigor, — debility, — or  senile  atrophy. 

In  old  women  Ave  not  infrequently  find  all  the  genital  organs  in  a 
state  of  abnormal  relaxation  from  loss  of  fibrous  tissue. 

Instead  of  normal  atrophy,  in  which  the  parts  are  condensed,  as 
the  fibrous  tissue  disappears,  there  is  no  contraction,  and  the  uterus, 
vagina,  and  perineum  are  reduced  to  their  membranous  structures, 
incapable  of  resisting  force  in  any  form.  Subinvolution  of  the  vagina, 
bladder,  and  rectum,  on  account  of  the  vascularity  and  laxity  attend- 
ant upon  that  condition,  permit  displacements,  which  are  favored  by 
the  weight  of  these  and  other  pelvic  organs. 


RECTOCELE.  481 

Eetention  of  the  urine  and  faeces  are  also  important  factors  in  the 
displacements.  They  distend  and  weaken  the  walls  of  the  viscera 
until  they  become  incapable  of  resisting  the  pressure. 

Treatment. 

The  same  general  principles  govern  the  treatment  of  these  two 
conditions. 

If  the  perineum  be  deficient,  its  integrity  should  be  restored  by 
perineorrhaphy,  and  this  will  often  be  sufficient  to  etfect  a  cure  of 
either  or  both. 

When  there  is  no  loss  of  perineum,  or  the  deficiency  is  slight,  we 
may  often  cure  cystocele  by  returning  and  retaining  the  prolapsed 
portion  in  position  until  the  redundancy  of  tissue  is  reduced  by  the 
contraction  and  condensation  which  take  place  when  the  distending 
forces  are  removed  or  counteracted. 

The  instrument  which  I  have  found  most  serviceable  in  cystocele  is 
Zwank's  pessary.  (Fig.  242).  The  points  upon  which  it  rests  are  the 
rami  of  the  ischium,  and  it  presents  the  fiat  surface  of  its  expanded 
wings  upward,  affording  an  admirable  lodging-place  for  the  redundant 
tissue.  The  application  of  this  instrument  is  not  difficult,  and  when 
of  the  right  size  it  very  generally  relieves  the  symptoms  at  once, 
especially  the  irritableness  of  the  bladder.  It  will  be  necessary  for 
the  patient  to  wear  the  pessary  for  many  months  until  the  condensa- 
tion or  involution  is  complete.  Like  every  other  pessary,  this  one 
should  be  removed  and  examined  often  enough  to  insure  cleanliness 
and  prevent  damage  to  the  vagina. 

If  it  causes  ulceration  it  must  be  removed  at  once.  .  Sometimes  a 
ring,  kept  in  position  by  external  support,  may  be  made  to  retain  the 
procident  wall  quite  securely.  The  practitioner  should  rely  upon 
the  pessary  in  most  instances  of  this  kind  as  far  preferable  to  other 
surgical  means,  except  the  restoration  of  the  perineum  when  deficient. 

When  a  surgical  operation  is  required,  the  object  to  be  attained  by 
it  is  to  remove  a  portion  of  the  redundant  mucous  membrane  over 
the  central  part  and  draw  the  edges  together,  and  thus  lessen  the 
calibre  of  the  vagina. 

To  the  inexperienced  this  operation  seems  a  formidable  one,  but  it 
is  not  so,  and  when  attempted  the  difficulties  will  rapidly  vanish. 
In  the  natural  condition,  the  mucous  membrane  of  the  vagina  is 
attached  to  the  fibrous  sheath  by  very  loose  connective  tissue.  In 
cystocele  the  space  is  much  greater,  hence,  with  a  tenaculum  we  can 
lift  the  membrane  freely  away  from  the  vaginal  sheath  and  with  the 
scissors  remove  it  to  any  extent  we  desire. 

As  before  remarked,  the  protrusion  in  many  instances  is  made  up 

of  the  mucous  membrane  alone,  when  the  operation  is  easy  and  a 

complete  success. 

31 


482       DISPLACEMENTS    OF   THE    VAGINA,    BLADDER,    AND    RECTUM. 

When  the  fibrous  wall  of  the  vesico-vaginal  space  yields,  and  is 
prolapsed  with  the  mucous  membrane,  the  operation  is  much  more 
likely  to  fail,  and  we  will  at  last  be  obliged  to  resort  to  a  support. 

Marshall  Hall  was  the  first  to  remove  pieces  of  the  anterior  vaginal 
wall,  but  he  limited  his  amputations  to  the  protruding  folds.  J.  Ma- 
rion Sims  denuded  an  oval  surface  extending  back  nearly  to  the  os 
uteri  and  closed  by  transverse  superficial  sutures.  Stoltz  removes  a 
circular  piece  of  mucous  membrane  and  draws  it  together  by  a  silk 
thread  passed  completely  around  the  circle  in  and  out  of  the  mucous 
membrane,  about  an  eighth  of  an  inch  from  the  edge. 

When  the  urethral  fossEe  and  anterior  vaginal  sulci  are  loosened  from 
their  facial  attachments  behind  the  pubes,  and  sag  down  along  with 


Stoltz's  Denudation  for  Cystocele  (Mund6). 


the  central  ridge,  I  prefer  to  remove  two  small  oval  strips  in  the  ure- 
thral fossse  extending  back  along  the  sulci  (Fig.  234).  The  tissue 
in  the  fossse  should  be  removed  deep  enough  to  get  to  the  firmer 
fascia  so  that  the  edges  of  the  denudation  will  be  held  up  by  it.  The 
denudation  may,  in  case  the  whole  vaginal  septum  be  relaxed,  be 
made  to  extend  backward  along  the  sulci  and  be  joined  under  the 
neck  of  the  bladder  by  a  transverse  strip,  as  in  Fig.  235. 

In  this  way  the  anterior  vaginal  walls  are  drawn  up  into  the  sulci, 
or  to  the  vesico-vaginal  septum,  and  as  nearly  as  possible  reattached 
behind  the  pubes  by  deep  stitches.  Care  must  be  taken  that  the 
strips  be  not  too  wide  or  the  traction  upon  the  stitches  will  be  too 
great.  (For  particulars  as  to  these  operations,  see  Operations  upon 
the  anterior  vaginal  wall  for  Prolapse  and  Procidentia,  p.  501). 


EECTOCELE.  483 

Judging  from  my  own  observation,  I  should  say  that  rectocele  is 
hardly  curable  in  any  other  way  than  by  operation.  The  perineum 
is  almost,  if  not  always,  deficient,  which  requires  an  operation  for  its 
restoration.  When  this  is  the  case,  the  two  may  be  cured  by  the  same 
operation.     (Chapter  VII.) 

Dr.  Gillette,  of  New  York,  performs  an  operation  for  condensing  the 
mucous  membrane  without  removing  it,  by  passing  silk  ligatures 
between  the  membrane  and  the  fibrous  sheath  and  drawing  it  up  over 
the  most  protuberant  portion. 

The  after-treatment  is  of  great  importance.  The  patient  should  be 
kept  quiet  in  bed  and  have  opium  enough  to  relieve  pain,  and  in  cys- 
tocele  the  urine  should  be  evacuated  by  the  catheter  often  enough  to 
prevent  distension.  In  rectocele  the  rectal  tube  must  be  used  to  pre- 
vent the  accumulation  of  gas,  and  the  bowels  moved  by  saline  laxatives 
every  other  day.  Salines  should  be  used  because  they  liquefy  the 
stools. 


CHAPTEE   XXIX. 

DISPLACEMENTS  OF  THE  UTERUS. 

The  uterus  is  normally  located  at  or  near  the  centre  of  the  pelvis, 
extending  from  the  pelvic  brim  or  slightly  below  it,  to  within  an  inch 
of  the  coccyx.  Its  long  axis  changes  its  direction  or  inclination  with 
the  filling  or  emptying  of  the  bladder  and  rectum,  with  the  different 
positions  of  the  body,  and  with  the  variations  in  abdominal  pressure. 
In  the  standing  posture  the  relatively  increased  direct  abdominal 
pressure,  and  its  own  weight,  carries  the  fundus  downward  over  the 
bladder;  in  the  dorsal  decubitus  the  relatively  increased  backward 
or  reflected  pressure,  and  its  weight,  carries  it  slightly  backward.  In 
recumbent  postures,  however,  the  abdominal  pressure  has  but  a  feeble 
effect  upon  the  position  of  the  uterus  and  allows  it  to  move  freely 
among  the  viscera.  The  action  of  its  supports  is  then  paramount, 
and  is  sufficient  to  restore  and  keep  its  axis  in  close  relationship  with 
the  axis  of  the  superior  strait. 

An  abnormal  location  of  the  entire  organ,  independent  of  any  alter- 
ation of  its  shape  or  the  direction  of  its  axis,  constitutes  a  dislocation 
or  simple  displacement;  an  abnormal  position  or  direction  of  its  axis, 
is  called  a  version ;  an  abnormal  curve  of  its  axis,  or  the  relation  of  its 
parts,  is  called  a  flexion. 

Simple  displacements  may  take  place  in  any  direction,  and  may  be 
called  forward  displacements,  or  ante-location;  backward  displace- 
ments, or  retro-location ;  right  or  left  lateral  displacements,  dextro- 
and  sinistro-locations ;  upward,  or  elevation;  and  downward,  in  the 
direction  of  the  axis  of  the  superior  strait,  constituting  descent,  or 
lapsus.  Descent  of  the  uterine  axis  on  the  curve  of  the  pelvic  axis  is 
called  prolapse,  and  if  beyond  the  pelvic  outlet,  protrusion  or  proci- 
dentia. (See  Fig.  221).  The  inverted  vagina,  the  rectum,  the  bladder, 
the  small  intestines,  one  or  all,  may  also  come  outside  of  the  pelvis 
with  the  protruded  uterus. 

In  cases  occurring  in  childbearing  M^omen,  the  bladder,  or  rectum, 
or  both,  may  precede  the  uterus,  and  often  act  partly  as  a  cause  of  the 
prolapse,  by  pulling  the  uterus  down  to  or  through  the  injured  or 
lacerated  pelvic  outlet.  In  nullipars  the  uterus  and  inverted  vagina 
protrude  first  and  may  or  may  not  drag  the  rectum  and  bladder  after 
them. 

Versions  are  forward,  anteversions ;  backward,  retroversions;  right 


DISPLACEMENTS    OF   THE    UTERUS. 


485 


or  left,  dextro-  and  sinistro-version,  according  as  the  fundus  turns  in 
any  of  the  directions  mentioned.  The  altered  position  of  the  fundus 
is  accompanied  by  a  turning  of  the  lower  end  of  the  cervix  in  the  op- 
posite direction,  upon  the  cervical  attachments  as  an  axis. 

Flexions  have  the  same  nomenclature  as  the  versions,  and  are  forward, 
backward,  or  lateral,  according  as  the  concavity  is  formed  by  an 
anterior,  posterior  or  lateral  uterine  wall. 

Two  or  all  of  these  three  varieties  of  deviations  may  occur  in  the 
same  case,  for  instance,  anteflexion,  retroversion  and  retrolocation 
(Fig.  225). 

Fig.  221. 


Pathological  Changes  in  Location  of  the  Uterus.    Dislocations. 

normal  position. 


The  dotted  lines  show  the 


In  some  cases  it  is  better  for  the  sake  of  accuracy  to  mention  the 
parts  dislocated.  For  example,  in  case  of  anteflexion  we  may  have 
merely  a  forward  displacement  of  the  fundus,  or  of  both  fundus  and 
lower  end  of  cervix,  or  we  may  have  a  backward  displacement  of  the 
upper  end  of  cervix,  or  of  the  corpus  with  a  normal  location  or  for- 
ward inclination  of  the  fundus  alone,  or  lower  end  of  cervix  alone  or 
of  both.  We  may  have  a  displacement  of  the  cervix  to  the  left  with 
fundus  in  a  normal  location;  or  a  displacement  of  the  fundus  to  the 
right  with  the  cervix  in  the  normal  position,  yet  either  would  be  called 
a  right  lateral  version  (dextro- version). 


486  DISPLACEMENTS   OF   THE    UTEEUS. 

What  Constitutes  a  Displacement  of  the  Uterus. 

The  normal  variations  in  location  and  position  of  the  whole  or  a 
part  of  the  organ  have  been  termed,  by  some,  physiological  displace- 
ments. Thus  when  the  bladder  is  empty  the  fundus  is  pressed  over 
the  bladder  causing  the  uterus  to  bend  at  or  near  the  internal  os ;  when 
the  bladder  is  full  the  fundus  is  pressed  up  so  as  to  straighten  the 
organ;  the  flexion  thus  produced  is  called  a  physiological  flexion. 
The  same  may  be  said  of  a  flexion  of  the  cervix  forward  during  ful- 
ness of  the  rectum.  Such  displacements,  or,  more-properly  speaking, 
changes  of  accommodation  in  the  parts,  or  the  whole,  of  the  uterus  do 
not  interfere  with  its  normal  motions  or  functions. 

A  pathological  displacement  of  the  uterus  is  more  or  less  permanent 
and  interferes  with  its  normal  motion  and  healthy  functions.  For 
instance.  Fig.  1  represents  a  normal  position  of  the  uterus  when 
the  bladder  is  empty,  or  nearly  so.  If,  however,  the  uterus  remain  in 
this  position  during  filling  of  the  bladder  and  the  fundus  cannot,  ex- 
cept by  force  and  discomfort  to  the  patient,  be  raised  or  pushed  back- 
ward, the  organ  is  anteverted.  Or  there  may  be  a  greater  bend  in  the 
uterus  than  shown  in  Fig.  1,  without  constituting  a  pathological 
anteflexion,  but  when  the  axis  cannot  be  straightened  by  the  filling 
bladder  or*  variations  in  abdominal  pressure,  or  when  it  interferes 
with  functions,  it  is  pathological.  Sometimes,  however,  the  fundus 
may  be  found  turned  into  the  hollow  of  the  sacrum  at  one  examina- 
tion ;  at  another  it  may  be  found  lying  low  on  the  bladder.  In  such 
cases  the  normal  motions  are  interfered  with  on  account  of  the  in- 
ability of  the  supports  to  promjDtly  return  it  and  hold  it  in  the  centre 
of  the  pelvis,  and  we  observe  anteversion  and  retroversion  alternately. 

Causes  of  Uterine  Displacements. 

Elevation  is  caused  by  tumors  intimately  or  remotely  connected 
with  the  uterus  growing  up  out  of  the  pelvis  and  dragging  the  uterus 
up  with  them,  by  inflammatory  or  other  contraction  of  tissues  at  the 
pelvic  brim,  by  the  pressure  of  pelvic  tumor  or  abscess  below  or  beside 
the  uterus,  or  by  a  loss  of  substance,  or  imperfect  development.  In 
the  latter  case  the  lightness  of  the  organ,  and  the  comparatively  small 
surface  presented  to  abdominal  pressure  above,  give  the  uterine  sup- 
ports greater  elevating  power. 

Of  Descent  or  Lapse. 

Descent  or  lapse  is  brought  about  by  symmetrical  enlargement  of 
the  uterus — as  pregnancy  or  other  forms  of  congestion,  hypertrophy, 
hyperplasia,  subinvolution,  small  uterine  tumors,  etc.,  or  by  a  general 
relaxation  of  the  pelvic  supports  resulting  from  parturition,  extreme 
emaciation  or  debility,  overwork,  prolonged  lactation,  tuberculosis, 


OF  VEESIONS.  487 

etc.     Haste  in  getting  up  after  abortion  and  labor  at  term  affords  one 
of  the  most  common  causes,  and  acts  in  both  of  the  ways  mentioned. 

Of  Prolapse  and  Procidentia. 

Prolapse  and  procidentia  are  produced  by  the  same  causes  as  the 
last,  but  acting  in  a  greater  degree  upon  the  sacro-uterine  ligaments. 
Relaxation  of  these  posterior  supports  and  the  contiguous  connective 
tissue  from  tumors,  fecal  impaction  of  the  upper  rectum,  or  from 
rectal  or  peri-rectal  disease,  and  the  like  (with  but  little  change 
anteriorly),  may  cause  simple  prolapse,  or  descent  of  the  uterus  along 
the  pelvic  axis  toward  the  perineal  body.  In  procidentia  the  support- 
ing structures  of  the  uterus  are  all  relaxed,  but  the  sacro-uterine  to  the 
greatest  degree.  Perineal  lacerations  and  the  accompanying  drag  of 
congested  or  hyperplastic  vaginal  and  vulval  tissues  may  also  have 
much  to  do  in  the  etiology  of  both  of  these  displacements,  but  espe- 
cially the  latter.  Labor  is  the  most  frequent  originator  of  this  condi- 
tion. 

Of  Displacements  Forward,  Backward,  Sideways. 

Forward,  backward  and  lateral  dislocations  are  seldom  the  result  of 
a  heavy  uterus  or  of  a  weakened  system  of  supports,  but  rather  of 
traction  or  shrinkage  of  tissue  in  the  pelvis,  or  of  pressure  from  patho- 
logical growths.  Hematocele  and  contraction  in  the  pubo-uterine 
peritoneum  or  connective  tissue  are  the  common  causes  of  forward 
displacement,  or  ante-location.  Posterior  displacements  are  ordinarily 
due  to  contraction  of  peritoneal  inflammatory  deposits  over  or  beside 
the  sacro-uterine  folds  or  rectum,  to  relaxation  of  the  vesico-uterine 
ligaments  from  an  over-distended  bladder  or  habitual  physical  exer- 
cise in  stooping  or  leaning  postures.  Tumors  or  inflammatory  de- 
posits often  press  the  uterus  back.  The  lateral  displacements  result 
from  the  pressure  of  tumors,  abscesses,  or  inflammatory  masses,  or' 
from  relaxations  or  contractions  in  the  broad  ligaments.  . 

Of  Versions. 

Versions  are  caused  chiefly  by  asymmetrical  enlargements  of  the 
uterus,  by  tumors  or  deposits  pressing  or  drawing  the  fundus  or  cer- 
vix out  of  place,  or  by  misdirected  or  excessive  abdominal  pressure 
due  to  deformities,  tight  lacing,  sedentary  occupations,  etc.  In  the 
majority  of  cases  the  cervix  is  drawn  by  a  contraction  in  the  tissues 
about  it  so  that  the  abdominal  pressure  is  brought  to  bear  more 
directly  against  one  of  the  walls  of  the  uterus.  Thus  a  contraction  in 
the  sacro-uterine  ligaments  draws  up  the  lower  end  of  the  uterus  so 
that  the  posterior  wall  is  presented  to  the  abdominal  pressure,  and  the 
fundus  or  movable  end  is  borne  down  over  the  bladder,  while  the  ex- 
ternal OS  is  turned  backward  toward  the  sacrum  (Fig.  53).     Contrac- 


488 


DISPLACEMENTS    OF    THE    UTERUS. 


tion  in  the  vesico-vaginal  septum  pulls  the  cervix  forward  so  that 
when  the  bladder  fills  or  the  patient  lies  on  her  back  the  abdominal 
pressure  bears  upon  the  anterior  uterine  wall  and  turns  it  into  the 
hollow  of  the  sacrum,  and  the  os  forward  behind  the  pubes.  Figs.  46, 
47,  and  56  represent  retroversion  in  different  degrees.  Illustrations 
which  represent  the  uterus  as  passing  from  anteversion  to  retroversion 
or  from  one  degree  to  another  of  the  same  version  upon  the  external 
OS  as  a  pivot  are  incorrect,  for  the  pivot  is  not  only  near  the  internal 
OS,  but  the  pivot  itself  usually  moves  backward  in  anteversion  and  for- 
ward in  retroversion.     (Figs.  229  and  230.) 

Lateral  versions  take  place  according  to  the  same  principles. 

Contraction  of  the  round  ligaments,  or  peritoneum  about  them,  may 
cause  an  anteversion  without  much  change  in  the  position  of  the  inter- 
nal OS.  Fig.  50  represents  this  somewhat  rare  form ;  compare  with 
Fig.  53. 

Fig.  222. 


Pathological  Anteflexion  causeu  by  a  Sliortening  of  the  Sacro-uterine  Ligaments. 

Schultze. 


After  B.  S. 


One  of  the  common  varieties  of  retroversion  is  combined  with  slight 
lateral  version,  and  is  produced  by  a  puerperal  or  non-puerperal 
relaxation  of  all  the  pelvic  supports  except  at  a  limited  area  of  atro- 
phic or  cicatricial  contraction  at  one  side  of  the  cervix.  This  contrac- 
tion holds  up  the  cervix  from  the  pelvic  floor,  but  hinders  the  normal 
forward  inclination  of  the  corpus  and  backward  inclination  of  the  cer- 


OF   FLEXIONS. 


489 


vix ;  as  a  consequence  the  fundus  is  forced  back  until  it  finds  rest  upon 
the  rectum  or  between  the  sacro-uterine  folds  or  in  one  of  the  lateral 
sacral  pouches.  In  such  position  the  fundus  finds  support  and  the 
tender  ligaments  rest,  and  the  uterus  thus  often  lies  in  greater  comfort 
than  when  replaced.  Whenever  absorption  of  such  deposits  and  ad- 
hesions takes  place  and  relaxation  occurs  over  the  area  of  previous 
contraction,  the  last  support  of  the  uterus  is  gone  and  it  becomes  pro- 
lapsed or  protruded. 

Another  important  factor  in  the  causation  of  versions  are  injuries  of 
the  pelvic  floor  and  perineum,  or  inefficiency  of  the  same  structures 
from  atony  or  debility.  They  act  less  directly  than  in  cases  of  pro- 
lapse and  procidentia,  but  often  with  none  the  less  effect. 

0/  Flexions. 

Flexions  may  be  caused  by  the  same  influences  already  given  for 
version,  but  the  resistance  at  the  cervical  attachments  causes  the  uterus 


Fig.  223. 


Anteflexion  produced  by  Contraction  in  or  about  the  Round  Ligaments. 

to  bend  instead  of  turning  on  the  cervical  pivot,  i.  e.,  a  hard  uterus 
will  twist  the  cervical  attachments  and  turn  over,  a  flabby  uterus  will 
bend.  The  healthy  uterus  will  bend  slightly,  and  then  slightly  twist 
the  cervical  attachments  in  its  normal  range  of  motion.  When  the 
bladder  is  empty  the  fundus  leans  over  the  bladder  partly  at  the  ex- 


490 


DISPLACEMENTS    OF    THE   UTERUS. 


pense  of  a  flexure  of  the  uterine  body  and  partly  by  a  slight  twisting 
of  the  lower  portion  of  the  broad  ligaments.  When  the  bladder  fills 
the  uterus  is  strengthened  and  the  lower  portion  of  the  broad  ligament 
untwisted  and  slightly  twisted  in  the  opposite  direction.  Such  flexion 
and  version  are  normal. 

But  when  the  uterus  is  drawn  back  or  the  fundus  held  down,  so 
that  the  natural  forces,  such  as  the  filling  of  the  bladder  and  dorsal 
decubitus,  cannot  straighten  it,  then  the  flexion  becomes  pathological, 
and,  sooner  or  later,  the  organ  becomes  disordered  in  function  or  inter- 
feres with  functions  of  other  organs.  After  a  time  the  concave  side 
becomes  atrophied  or  intractile,  and  the  flexion  permanent.  Fig.  222 
represents  an  extreme  degree  of  anteflexion  due  to  contraction  of  the 
sacro-uterine  folds.  Flexion  caused  by  contraction  about  the  round 
ligaments  is  usually  situated  more  in  the  cervix,  as  in  Fig.  223. 

The  pressure  of  the  posterior  vaginal  wall  and  contents  of  the  rec- 
tum against  the  lower  end  of  the  cervix  in  the  latter  case  bends  it  for- 


Fio.  224. 


Puerile  Anteflexion.    After  B.  S.  Schultze. 


ward,  and  thus  keeps  it  from  being  turned  back  toward  the  sacrum, 
as,  for  example.  Fig.  222. 

When  the  posterior  vaginal  wall  is  short,  and  the  sacro-uterine  and 
round  ligatnents  both  rigidly  contracted,  or  naturally  short,  in  earl}' 


OF   FLEXIONS. 


491 


life,  the  external  os  and  fundus  may  be  both  turned  forward  until  the 
cervix  and  corpus  lie  parallel  to  each  other,  both  pointing  forward 
toward  the  pubes  or  pelvic  outlet,  as  in  Fig.  224. 

After  the  causative  influences  have  ceased  working,  or  after  the  liga- 
ments, by  removal  of  the  contracting  deposits,  or  by  the  development 
of  puberty  or  married  life,  have  been  relaxed  or  elongated,  the  flexure 
(on  account  of  atrophy  or  intractility  of  the  concave  side)  may  remain, 
and  the  fundus,  or  whole  uterus,  sink  toward  the  coccyx,  and  a  retro- 
location  or  retroversion  be  found  along  with  the  anteflexion,  as  repre- 
sented in  Fig.  225. 

When  the  fundus  becomes  pushed  or  pulled  back  of  the  pelvic 
axis,  abdominal  pressure  helps  to  force  the  fundus  back  in  the  recto- 


FlG.  225. 


Anteflexion  with  Retroversion  and  Eetrolocation. 


uterine  or  sacral  peritoneal  pouches,  while  the  traction  of  the  sacro- 
uterine ligaments  tends  to  draw  back  the  cervix  to  its  normal  position 
and  thus  flex  the  uterus  at  or  above  the  internal  os.  If  the  organ  be 
unusually  flabby,  as  it  is  apt  to  become  when  thus  distorted,  the  cer- 
vix and  corpus  may  be  bent  so  as  to  lie  against  each  other  (Fig. 
226).  When  the  cervix  is  drawn  forward  by  inflammatory  contrac- 
tions beside  and  in  front  of  it,  the  flexion  is  usually  less  acute  in 
degree  and  is  distributed  over  the  whole  uterus  or  is  confined  to  the 
corpus.  The  fundus  usually  does  not  lie  as  low,  for  in  consequence 
of  the  previous  inflammation  at  the  cervix  the  uterine  tissue  is  firmer 
and  does  not  allow  of  such  complete  flexion. 


492 


DISPLACEMENTS    OF   THE    UTERUS. 


Contraction  of  peritoneal  exudates  is  supjDosed  to  be  one  of  the 
most  frequent  causes  of  the  extreme  retroflexion  represented  in  Fig. 
226,  for  such  flexion  occurs  after  inflammatory  attacks  (esiDCcially  the 
puerperal)  and  is  often  complicated  by  adhesions  between  the  fundus 
and  posterior  surfaces  of  the  broad  ligament  with  the  rectum  and  pos- 
terior pelvic  walls.  I  have  in  a  few  cases  noted  a  gradual  increase 
in  the  flexion  due  to  a  diminishing  resistance  of  the  cervical  tissue 
and  the  increasing  traction  of  the  sacro-uterine  folds. 

Because  of  this  moderate  degree  of  retroflexion  that  is  usually  found 
in  cases  of  retroversion  the  Germans  call  nearly  all  of  them  retro- 

FlG.  226. 


Extreme  Retroflexion. 


flexions  or  retroversio-flexions ;  on  account  of  the  retroversion  that  is 
found  in  nearly  all  cases  of  moderate  retroflexions,  these  latter  are 
more  often  classed  in  this  country  with  retroversions.  Retroversion 
with  flexion,  or  retroflexion  with  version,  would  not  be  inappropriate. 
Some  cases  of  flexion  are  due  to  congenital  causes,  but  like  other 
congenital  deformities  are  rare.  Flexion  acquired  before  puberty  is 
undoubtedly  much  more  common,  and  is  often  classed  as  congenital. 
Malnutrition,  improper  feeding,  sedentary  habits,  muscular  atony  and 
the  like  tend  to  arrest  the  development  and  impair  the  nutrition  of 
the  uterus.     A  comparison  of  Figs.  227  and  228  will  give  an  idea  of 


TORSION   OR   TWISTING. 


493 


the  different  kind  of  pressure  to  which  the  uterus  is  subjected  in  a 
woman  who  stands  erect  and  one  who  habitually  stoops.  It  is  just 
as  likely  that  the  woman  who  sits  and  sews  by  hand  or  on  a  machine 
for  eight  hours  a  day  during  a  period  of  several  years  will  suffer  with 
some  form  of  uterine  displacement  or  deformity,  as  that  she  will 
begin  to  stoop  in  her  gait  or  suffer  with  dyspepsia  or  derangement 
of  other  internal  organs.     Continual  standing  also  tends  to  uterine 


Fig.  227. 


Fig.  228. 


Natural  Position  of  the  Body. 


Unnatural  or  Stooping  Position 
of  the  Body. 


flexion  and  displacement,  because  the  abdominal  pressure  is  continu- 
ous, and  without  that  variation  and  general  tonic  effect  that  goes  with 
varied  exercise. 

Lateral  flexions  are  usually  caused  by  extensive  contraction  of 
tissue  from  inflammation  beside  the  uterus,  with  or  without  tumors, 
enlargements  or  abscesses  in  or  about  the  ovaries  and  Fallopian  tubes. 


Torsion  or  Twisting. 

Torsion  or  twisting  of  the  uterus  to  an  unnatural  degree  may  result 
from  pressure  or  traction  forward  or  backward  at  one  horn  of  the 
uterus,  or  at  one  side  of  the  cervix.  The  most  common  causes  are  a 
contraction  in  or  about  one  sacro-uterine  and  one  broad  ligament  (Fig. 
52),  and  along  or  near  the  course  of  one  round  ligament.  A  sim- 
ultaneous backward  or  forward  version  or  flexion  is  also  found  in 
most  cases — sometimes  a  lateral  version. 


494  DISPLACEMENTS   OF    THE   UTERUS. 

Symptoms  of  Uterine  Displacement. 

The  particular  jjlace  or  position  of  the  womb  may  not  directly  give 
rise  to  any  characteristic  symptoms  until  the  organ  commences  to 
press  at  the  pelvic  outlet.  The  coexisting  displacements,  distortions 
or  pathological  conditions  of  the  surrounding  structures,  whether  the 
causes  or  results,  usually  cause  the  great  bulk  of  symptoms. 

When  the  uterus  is  much  enlarged  its  weight  causes  irritation  or 
inflammation  of  the  tissues  upon  which  it  presses,  with  the  symptoms 
belonging  to  such  troubles.  Traction  upon  tender  tissues  also  cause 
similar  symptoms.  Thus  retroversion  by  traction,  and  anteversion  by 
pressure,  upon  a  tender  bladder,  may  cause  vesical  irritability ;  or 
retroversion  by  pressure  and  anteversion  by  traction  upon  a  tender 
rectum  may  cause  pain  in  the  rectum  or  sacrum. 

Pains  due  to  displacement  are  apt  to  be  localized  and  persistent, 
and  increased  in  certain  postures  and  by  certain  occupations.  Ante- 
versions  and  antefiexions  are  nearly  always  accompanied  by  decided 
symptoms,  especially  during  the  menstrual  congestion,  because  the 
weighted  uterus  is  suspended  or  held  from  fixed,  and  usually  inflamed, 
tissues.  Retroversion  and  retroflexion  are  much  less  often  associated 
with  painful  symptoms,  because  the  fundus  finds  a  resting  place  be- 
hind, and  hence  does  not  drag  so  heavily  upon  inflamed  parts.  Even 
when  the  twisting  of  the  broad  ligament  produced  by  the  displace- 
ment is  primarily  painful,  the  state  of  rest  of  the  organ  often  favors 
a  subsidence  of  the  inflammation,  and  particularly  so  if  the  recto- 
vaginal promontory  and  posterior  vaginal  wall  are  high  and  firm 
enough  to  afford  indirectly  some  support  to  the  cervix,  turned  for- 
ward over  them.  Pain  in  one  iliac  region  is  often  caused  by  the  trac- 
tion of  an  ante  verted  or  retro  verted  uterus  when  complicated  by  a 
contracted  broad  ligament.  Constipation  is  often  a  result  of  the 
pressure  of  a  retroverted  organ  upon  the  rectum,  but  may  also  be 
caused  by  the  induration  and  contraction  in  the  sacro-uterine  liga- 
ments encircling  the  rectum  in  case  of  anteversion. 

Sterility  is  more  often  a  symptom  of  anteflexion  than  of  retroflexion 
or  retroversion,  and  more  often  of  decided  retroflexion  than  of  retro- 
version. Extreme  lateral  version  or  flexion  are  also  apt  to  be  accom- 
panied by  sterility,  due,  however,  to  its  cause.  Retroversion  although 
seldom  a  cause  of  sterilit}^  is  not  infrequently  a  cause  of  abortion. 

Protrusion  may  give  rise  to  faintness,  dragging  sensations  about  the 
pelvis,  indigestion,  inability  to  endure  continuous  exertion,  irritability, 
hysteria,  local  irritation  and  ulceration,  and  in  some  cases  renders  the 
erect  position  unbearable,  and  life  a  burden. 

The  symptoms  of  uterine  displacement  are  so  variable  and  so  inti- 
mately connected  with  the  pelvic  diseases  that  I  do  not  attempt  to  give 
all  that  are  observed,  but  enough  to  enable  the  student  to  understand 


DIAGNOSIS   OF   UTERINE   DISPLACEMENTS. 


495 


their  nature,  ^nd  appreciate  the  relation  of  the  symptoms  to  the  dis- 
placement, which  in  reality  is  itself  but  a  symptom  among  the  others 
of  some  pelvic  disease  or  disorder. 


Diagnosis  of  Uterine  Displacements. 

For  a  diagnosis  of  the  positions  of  the  uterus  the  reader  is  referred 
to  Chapter  II.  It  will  only  be  necessary  here  to  give  a  few  facts  rela- 
tive to  the  differential  diagnosis.  One  of  the  first  and  most  important 
points  is  to  determine  the  place  and  position  of  the  cervix.     Antever- 


FlG.  229- 


Anteversion  and  Retroversion  (Schematic),  after  B.  S.  Schultze,  illustratiii^  i.ie  Changes  in 

Location  of  the  Lower  End  of  the  Cervix  (^).    n,  normal  position  of  uterine  cavity ; 

a,  anteversion ;  r,  retroversion. 

sion  of  a  full-sized  uterus  scarcely  ever  exists  when  the  lower  end  of 
the  cervix  is  two  inches  or  less  from  the  pubic  arch ;  nor  retroversion 
when  it  is  more  than  two  inches.  Fig.  229  illustrates  the  changes  in 
position  of  the  lower  end  of  the  cervix  in  anteversion  and  retroversion, 
and  Fig.  230  between  anteflexion  and  retroflexion.  The  uterine  cavi- 
ties only  are  represented. 

Anteflexion  with  retroposition  or  retroversion  is  often  mistaken  for 


496 


DISPLACEMENTS    OF   THE    UTERUS. 


ordinary  retroversion  because  the  cervix  extends  forward  in  the  vaginal 
axis,  and  its  posterior  wall  is  felt  as  far  as  the  finger  can  reach  extend- 
ing as  a  flat  or  slightly  convex  surface  (antero-posteriorly)  towards  the 
sacrum  (Fig.  224).  By  placing  the  finger  tip  against  the  os  and  rais- 
ing the  side  of  the  finger  against  the  inferior  pubic  ligament  in  one  of 
the  urethral  notches,  it  will  be  immediately  perceived  by  measurement 
that  there  is  no  room  for  the  fundus  between  the  cervix  and  the  sacrum 
unless  the  uterus  be  flexed.  If  flexed  backward  the  fundus  will  of 
course  be  easily  reached  behind  the  concave  cervical  wall.  If  the  os 
point  toward  the  pubes  or  vulva  and  be  less  than  two  inches  from  the 
pubic  arch  there  is  retroversion  (Fig.  229)  or  retroflexion  (Fig.  230)  or 

Fig.  230. 


Anteflexion  and  Retroflexion  (Schematic),  after  Schultze,  showing  the  Changes  in  Location  of 
the  Lower  End  of  Cervix.    ?i,  normal  position  ;  a,  anteflexion  ;  r,  retroflexion. 


else  the  fundus  will  be  reached  in  the  bimanual  examination.  Should 
an  anteflexed  uterus  be  drawn  too  far  back  to  be  palpated  bimanually, 
the  tense  sacro-uterine  ligaments  may  be  felt  behind  the  cervix. 

An  unusual  length  of  the  anterior  vaginal  wall,  from  the  inferior 
pubic  arch  to  the  cervico-vaginal  junction  (over  21  inclies)  is  diag- 
nostic of  the  great  majority  of  cases  of  anteversion  (229  a)  or  anteflexion 
(230  a) — it  is  much  greater  than  in  retroversion  and  retroflexion  (r). 


DIAGNOSIS   OP    UTERINE   DISPLACEMENTS.  497 

The  ease  with  which  the  fundus  can  be  reached  bimanually  is  of 
great  importance.  A  knowledge  of  the  location  of  the  fundus,  the 
vaginal  junction  and  the  external  os  gives  as  accurate  information  as 
to  the  shape  and  position  of  the  whole  organ,  even  when  the  entire 
anterior  or  posterior  surface  cannot  be  palpated. 

Retrouterine  tumors  are  liable  to  be  mistaken  for  retroflexions  or 
even  retroversions.  The  finger  should  be  pressed  as  far  up  the  ante- 
rior and  lateral  cervical  wall  as  possible  in  search  of  the  body.  If  the 
body  be  not  thus  detected  over  the  retrouterine  mass,  it  should  be 
searched  for  bimanually.  Its  absence  of  course  would  prove  the  sup- 
posed tumor  to  be  the  fundus.  The  probe  will  pass  backward  if  it  be 
the  fundus,  but  upward  over  it  if  it  be  a  retrouterine  tumor.  The 
tumors  most  liable  to  be  thus  mistaken  are  retrouterine  hematocele, 
fibroid  in  posterior  uterine  wall,  small  ovarian  tumor,  faeces  in  the  rec- 
tum, and  inflammatory  or  malignant  deposits. 

The  diagnosis  of  procidentia  is  easy  because  the  cervix  and  urethra 
are  visible  and  can  be  probed.  The  uterus  can  also  be  returned  and 
then  palpated.  In  prolapse  the  cervix  is  found  by  the  finger  pointing 
almost  in  the  direction  of  the  vaginal  axis,  less  than  two  inches  from 
the  pubic  arch,  and  lying  on  or  at  the  recto-vaginal  promontory.  The 
uterine  probe  passes  up  in  the  direction  of  the  curve  of  the  pelvic 
axis  or  nearly  so. 


32 


CHAPTER    XXX. 

DISPLACEMENTS  OF  THE   UTERUS  {Continued). 

Treatment  of  Uterine  Displacements. — Prophylactic. 

A  LARGE  proportion  of  the  uterine  displacements  and  deformities  are 
acquired  before  and  soon  after  puberty,  and  the  majority  of  those 
acquired  later  are  from  causes  originating  in  pregnant  and  puerperal 
conditions.  Much  can  therefore  be  done  in  the  rearing  of  children  to 
prevent  these  troubles.  Fewer  hours  of  sitting,  more  hours  of  active 
outdoor  exercise  are  required.  The  menstruating  girl  should  be  taught 
to  rest  during  menstruation.  The  harmful ness  of  retaining  the  urine 
uncomfortably  long,  and  the  necessity  of  a  daily  movement  of  the 
bowels  should  be  impressed  upon  her  mind.  Her  food  should  be  of  a 
healthful  kind.  Anaemia,  debility,  nervous  peculiarities,  etc.,  should 
receive  prompt  attention.  Especially  should  the  least  menstrual  ir- 
regularity be  made  the  subject  of  watchful  study. 

After  a  miscarriage  a  woman  should  remain  in  bed  as  long  as  after 
labor,  and  after  both  she  should  be  carefully  watched  by  the  physician 
until  involution  is  safely  and  completely  accomplished.  If  she  have 
at  the  time,  or  previously,  suffered  with  laceration  or  inflammation  of 
the  pelvic  tissues,  she  should  remain  in  bed  two  or  three  weeks  instead 
of  the  usual  eight  or  ten  days.  Immediate  repair  of  extensive  lacera- 
tions is  of  prime  importance.  • 

Treatment  of  Simple  Dislocations,  Upward,  Forward  and  Backward. 

The  treatment  of  displacement  of  the  uterus  upward,  forward  or 
backward  consists  almost  entirely  in  the  removal  of  the  displacing 
cause.  Pending  this  it  is  often  necessary  to  support  the  uterus  in  its 
malposition  and  thus  relieve  the  tender  and  perhaps  rigid  supports 
from  the  abdominal  pressure  and  the  weight  of  the  organ.  Cotton 
tampons  soaked  in  glycerine,  placed  under  and  around  the  cervix  in 
the  morning  and  removed  at  night,  form  the  best  kind  of  support. 
They  may  be  introduced  through  the  speculum  in  the  dorsal  position, 
and  should  not  be  made  of  absorbent  cotton  which  packs  too  hard, 
but  of  the  best  quality  found  in  the  dry-goods  stores.  A  string  should 
be  attached  to  each  to  facilitate  its  removal. 

For  elevation  due  to  inflammatory  conditions  of  the  pelvic  brim, 
one  tampon  about  the  size  and  shape  of  the  terminal  phalanx  of  the 
thumb  should  be  placed  in  each  lateral  fornix,  one  or  two  in  the  pos- 
terior fornix,  a  flat  one  under  the  cervix,  and  one  or  two  large  dry  ones 


SIMPLE    DISLOCATIONS,    UPWARD,    FORWARD,    AND    BACKWARD.       499 

in  front  of  the  cervix,  according  as  there  is  much  space  to  fill.  For 
retrolocations  the  tampons  are  placed  similarly  except  that  they  are 
left  out  of  the  posterior  fornix.  In  lateral  displacements  no  tampon, 
or  only  a  very  small  one,  should  be  put  in  the  lateral  fornix  on  the 
side  of  the  displacement,  but  a  proportionatel}^  large  one  should  be 
put  in  the  other  lateral  fornix.  They  may  be  placed  very  easily  by 
withdrawing  the  speculum  slightly  after  the  deeper  ones  have  been 
introduced. 

They  are  of  but  little  service  while  the  patient  is  in  a  recumbent 
position,  and  should  not  be  employed  until  the  acute  stage  of  inflam- 
mation has  passed,  and  the  patient  leaves  the  bed.  Nor  should  the 
pelvis  be  packed  too  full  of  them,  for  our  object  is  not  to  produce  con- 
stant upward  pressure,  which  would  be  intolerable,  but  to  place  a 
cushion  around  and  under  the  cervix  upon  which  it  may  settle  when 
the  erect  position  is  assumed,  and  which  will  thus  receive  all  increase 
of  abdominal  pressure  and  render  it  harmless. 

After  the  pelvic  inflammation  has  passed  into  the  chronic  stage  an 
inflated  rubber  ring  (Fig,  231)  maybe  used;  that  it  may  better  accom- 


FlG  231 


Soft  Rubber  Inflated  Pessaries. 


modate  itself  to  the  parts,  the  air  may  be  let  partly  out  with  a  pin 
and  the  pinhole  closed  with  melted  wax.  Some  of  those  in  the  stores 
have  a  piece  of  wax  on  the  inside  through  which  they  may  be  punc- 
tured, and  then  closed  by  pressure. 

Some  patients  can  wear  the  cotton  tampons  or  the  soft  pessary  con- 
tinuously, others  only  about  half  of  the  time.  When  it  is  not  con- 
venient to  replace  them  every  night  they  may  be  left  in  place  for 
thirty -six  hours,  then  removed  by  the  patient,  and  replaced  by  the 
physician  after  another  thirty-six  hours.  Strings  should  always  be 
attached  to  them  for  removal  by  the  patient  at  any  time  that  they  may 
cause  discomfort. 

In  some  cases  of  backward  dislocations  of  the  uterus  the  pressure 
of  the  abdominal  viscera  stretches  and  depresses  the  anterior  vaginal 


500  DISPLACEMENTS   OF   THE    UTERUS. 

wall  and  makes  it  desirable  to  introduce  a  retroversion  pessary  (see 
Treatment  of  retroversion)  which  will  turn  the  fundus  forward  over 
the  bladder,  and  will  also  press  upward  behind  the  pubes  with  its 
anterior  end,  such  as  a  Hodge,  Thomas,  Fowler  or  a  Schultze's  sleigh 
pessary.  In  case  the  bladder  be  separated  from  the  uterus  so  as  to 
allow  of  an  anterior  vaginal  enterocele,  a  permanent  fixation  forward 
of  the  fundus  by  shortening  the  round  ligaments  (see  Alexander's 
operation)  may  become  advisable. 

Descent  or  Lapse. 

When  the  uterus  sinks  down  in  the  axis  of  the  superior  strait  with- 
out losing  its  mobility,  either  the  ligaments  are  relaxed  or  the  uterus 
is  too  heavy.  Both  conditions  are  apt  to  be  present.  Particularly  is 
this  so  after  inflammatory  conditions  which  have  raised  or  drawn  the 
uterus  toward  the  pelvic  walls,  have  been  in  part  removed,  and  the 
congestion,  hyperplasia  or  subinvolution  persist.  The  uterine  sup- 
ports, weakened  partly  by  the  inflammatory  action,  and  partly  by 
long  inaction,  allow  the  heavy  organ  to  sink  down  against  the  rectum 
or  coccyx,  or  thereabout,  and  thus  become  permanently  overstretched 
and  subject  to  perpetual  irritation  and  congestion. 

The  indication  here  is  to  support  the  uterus,  and  relieve  the  trac- 
tion by  tampons  and  soft  pessaries.  The  tampons  are  placed  as 
already  directed  for  the  elevated  uterus,  and  may  be  used  thus  until 
the  irritation  in  part  subsides.     After  the  vagina  will  tolerate  a  pretty 

Fig.  232. 


Peaslee's  Elastic  Ring. 


full  packing  they  may  be  introduced  in  Sims's  position,  in  which  the 
uterus  is  drawn  away  from  the  pelvic  floor  as  far  as  its  supports  will 
comfortably  allow.  Some  prefer,  after  placing  two  or  three  glj^cerine 
tampons  about  the  cervix,  to  stuff"  one  large  piece  of  dry  cotton  or  fine 
wool  so  as  to  fill  the  vaginal  cylinder.  If  a  little  boracic  acid  has  been 
dusted  on  the  cotton  or  wool  it  may  remain  three  or  four  days,  then 
be  removed  and  replaced  immediately,  or  in  twenty-four  hours.  The 
inflated  soft  rubber  rings.  Fig.  231,  or  Peaslee's  elastic  ring  pessary, 
Fig.  232,  can  be  used  later.  Such  support,  especially  that  by  the 
tampons  soaked  in  glycerine,  by  removing  the  traction  and  irritation, 
often  relieves  both  pelvic  and  uterine  troubles,  and  promotes  involu- 
tion. 


TO  STRENGTHEN  OR  ELEVATE  THE  PELVIC  ROOF  SUPPORTS.   501 

Later,  if  these  means  fail,  the  uterus  may  be  reduced  by  electricity 
or  stimulating  medicines  applied  to  the  endometrium,  etc. 

Prolapse  and  Procidentia. 

Three  indications  are  to  be  considered  in  the  treatment  of  this  form 
of  displacement,  viz. :  to  diminish  the  weight  of  the  uterus  and  the 
other  prolapsed  structures,  to  strengthen  or  elevate  the  pelvic  roof 
supports,  and  to  restore  or  supplement  the  pelvic  floor  and  perineum. 

Measures  for  Diminishing  the  Weight  of  the  Uterus. 

When  subinvolution,  hyperplasia,  or  morbid  growths  occur  in  con- 
nection with  prolapse  and  procidentia,  they  must  be  treated  before  a 
satisfactory  cure  can  be  effected.  The  means  employed  to  reduce  the 
size  of  a  hyperplastic  or  subinvoluted  uterus  are  strong  galvanic  cur- 
rents applied  to  the  interior  of  the  uterus,  intrauterine  applications  of 
caustic  or  irritants,  ergot,  repair  of  cervical  lacerations,  the  amputation 
of  an  elongated  cervix,  or  an  excision  of  wedge-shaped  pieces  from 
the  external  os  in  case  the  cervix  be  elongated  supra-vaginally  or  en- 
larged merely  in  circumference. 

In  a  few  cases  the  whole  uterus  has  been  removed  per  vaginam. 
This,  as  Schroeder-!^  remarks,  is  not  now  as  formidable  f  n  operation 
as  formerly,  and  can  be  easily  executed  when  the  uterus  is  prolapsed 
or  protruded,  yet  cannot  be  considered  justifiable  unless  malignant 
disease,  gangrene,  or  other  equally  grave  indications  call  for  it,  i.  e., 
unless  the  complication,  not  the  displacement,  calls  for  it. 

Measures  to  Strengthen  or  Elevate  the  Pelvic  Roof  Supports. 

Operations  on  the  Anterior  Vaginal  Wall. — J.  Marion  Sims  denuded  a 
V-shaped  figure  from  the  anterior  vaginal  wall  with  the  apex  near  the 
urethra  and  the  ends  of  the  arms  just  in  front  and  on  either  side  of 
the  cervix.  The  denuded  strips  forming  the  V  are  about  a  third  of 
an  inch  wide,  and  when  united,  narrow  the  vagina,  more  particularly 
at  the  upper  end.  Emmet  found  that  the  cervix  sometimes  caught 
into  the  cavity  formed  under  the  united  arms  of  the  V  and  became 
retro  verted  or  otherwise  caused  the  patient  discomfort.  He  therefore 
modified  the  denudation  by  converting  the  V  into  a  triangle  (Fig. 
233).  This  operation  was  invented  for  the  purpose  of  narrowing  the 
vagina,  and  as  such  has  been  largely  supplanted  by  operations  on  the 
posterior  vaginal  wall.  But  as  a  means  of  drawing  together  the  re- 
laxed pelvic  roof-tissues  and  strengthening  them,  it  is  rational  and 
useful,  and  involves  less  mutilation  than  an  excision  of  a  large  oval 
or  round  piece  of  vaginal  wall.     It  is  preferable,  I  think,  to  combine 

*  Op.  cit. 


502 


DISPLACEME2sTS    OF    THE    UTEEQS. 


such  an  operation  with  perineorrhaphy  than  to  remove  as  large  a  part 
of  the  posterior  vaginal  wall  as  is  frequently  clone  in  posterior  colpor- 
rhaphy. 

When  the  parts  about  the  urethral  fossse,  or  lower  end  of  the  vaginal 
sulci,  are  the  ones  most  relaxed,  the  excision  of  two  narrow  strips 
from  the  fossge  (one  on  each  side),  diverging  as  they  extend  backward, 
may  be  indicated.  (Fig.  234).  These  strips  may  be  connected  by  a 
transverse  strip  under  the  neck  of  the  bladder  when  there  is  much 

Fig.  233. 


The  Sims-Emmet  Denudation  for  Cystocele  and  Procidentia, 
^.uterus;  ii,  urethra  ;  CCCC,  denuded  surface. 


redundancy  of  the  anterior  vaginal  wall  in  an  antero-posterior  direc- 
tion. (Fig.  235;.  The  stitches  of  the  transverse  denudation  take  an 
antero-posterior  direction,  those  of  the  lateral  a  diagonal  direction, 
Avith  reference  to  the  vaginal  axis.  The  object  is  to  draw  the  relaxed 
vaginal  wall  up  behind  the  pubes  into  the  sulci  and  urethral  fossfe. 

There  is  a  peculiarity  about  the  passing  of  the  sutures  in  the  ure- 
thral fossse  and  the  lateral  denudations  that  is  worthy  of  attention. 
They  should  be  passed  in  a  direction  diagonal  to  the  long  axis  of  the 
vagina  and  made  to  include  the  edges  of  the  wound  and  a  strip  of  the 


TO  STRENGTHEX  OR  ELEVATE  THE  PELVIC  EOOF  SUPPORTS.   503 

centre,  as  in  Fig.  236.  It  draws,  when  tightened,  the  edges  and  bottom 
of  the  wound  up  together  (237).  When,  however,  ordinary  stitches 
are  passed,  not  including  the  bottom  of  the  wound,  the  tissues  are 
folded  so  that  the  bottom  is  removed  as  far  as  possible  from  the  edges 
as  in  Fig.  238.     In  denudations  directly  under  the  urethra  and  bladder 


Fig.  234. 


Fig.  2f! 


I  Zlrcfkra 


Cerrt-x 


Cei'Vi^ 


Fig.  234.— Lateral  Denudation  in  the  Urethral  Fossee  and  Anterior  Vaginal  Sulci,  for  elevating 
and  strengthening  the  Pubic  End  of  the  Vesico-vaginal  Septum. 
Fig.  235.— Denudation  for  raising  and  strengthening  the  whole  Vesico-vaginal  Septum. 

in  the  median  line,  the  latter  are  better,  as  they  make  a  thicker  sep- 
tum. In  denudations  in  the  urethral  fossse  and  anterior  vaginal  sulci 
the  former  are  preferable  because  they  draw  the  vaginal  walls  up  to 
the  Connective  tissue  above. 

Recently  gynecologists,  especially  the  German,  have  gone  back  to 
Sims's  first  method  of  excising  an  oval  piece  of  the  anterior  vaginal 


Fig.  236. 


Fig.  237. 


Fig.  238. 


-^    ir 


Fig.  236.— Stitch  passed  so  as  to  catch  up  the  Bottom  of  the  Wound. 

Fig.  237.— Same,  united. 

Fig.  238.— Suture  passed  and  united  in  the  usual  manner. 

wall  and  drawing  the  edges  together  in  the  median  line.  Sims  used 
superficial  stitches  only,  and  sometimes  had  trouble  from  an  accumu- 
lation of  the  secretions  at  the  bottom  of  the  wound.  This  is  now 
obviated  by  the  employment  of  three  or  four  additional  deep  stitches. 


504  DISPLACEMENTS    OF   THE    UTERUS. 

or  by  uniting  the  deeper  portions  by  one  or  two  rows  of  buried  catgut 
sutures  as  recommended  by  Werth.* 

When  soaked  in  oil  of  juniper  for  24  hours,  and  then  preserved  in 
alcohol,  Kiister  claims  that  catgut  will  resist  absorption  for  nine  days 
(Schrceder,  op.  cit.).  A  continuous  suture  may  be  taken  along  the 
bottom  of  the  wound,  and  then  another  a  little  higher  up. 

Sometimes  the  entire  mucous  membrane  is  denuded  from  the  Sims- 
Emmet  triangle  and  united  by  transverse  deep  and  superficial  stitches. 

Cauterization. 

Cauterization  of  the  vagina  and  cervix  has  been  resorted  to  for  the 
reduction  of  redundant  tissue  and  the  strengthening  or  hardening  of 
the  uterine  supports.  Holes  have  been  burnt  into  the  cervix  with 
caustic  and  longitudinal  strips  of  the  vagina  have  been  cooked  by  the 
actual  cautery  and  electro-cautery. 

Recently  John  Byrne,t  of  Brooklyn,  has  employed  partial  and  com- 
plete amputation  of  the  cervix  and  vaginal  folds,  by  means  of  the 
galvano-cautery,  with  success.  In  some  cases  in  which  the  pelvic  con- 
nective tissue  has  completely  lost  its  tone  and  in  part  wasted  away, 
this  method  will  undoubtedly  prove  valuable  in  producing  a  cicatricial 
hardening  of  the  pelvic  roof  tissues. 

Partial  Closure  of  the  Vagina. 

Lefort's  method  of  denuding  a  median  strip  on  both  anterior  and 
posterior  vaginal  walls,  two  centimetres  wide  and  six  centimetres  long 
(I  X  2J  inches),  and  uniting  them,  has  proved  a  useful  operation.  The 
parts  may  be  denuded  while  protruded  and  returned  as  fast  as  they 
are  stitched,  commencing  of  course  with  the  deeper  portions.  A 
small  channel  for  the  passage  of  the  secretions  is  thus  left  on  either 
side. 

Well  prepared  catgut  may  be  used,  as  first  recommended  by  Panas,J 
and  thus  the  troublesome  removal  of  stitches  avoided. 

L.  A.  Neugebauer's  method  is  practically  the  same  as  Lefort's,  but 
his  surfaces  are  a  trifle  smaller. 

By  thus  practically  uniting  the  pelvic  roof  and  pelvic  floor,  the 
uterus  may  be  supported  when  the  vaginal  outlet  and  the  perineum 
are  destroyed  beyond  repair.  Martin  has  known  this  artificial  barrier 
to  give  way  under  the  strain  of  heavy  lifting,  and  allow  the  prolapse 
to  occur  again. 


*  Centralbl.   f.  Gyn.,  1879,  No.  23,  Schrceder-Krankh.   d.  Weibl.   Gechlechtrory, 
7th  fed. 

t  Transactions,  Am.  Gyn.  Soc,  vol.  ii. 

X  Winckel,  Lehrbuch  der  Fraiienkrankheiten. 


HYSTEROPHORES   OR   PESSARIES. 


605 


Abdominal  Section. 

P.  Mueller,  T.  G.  Thomas,  H.  Marion  Sims,  and  others,  have  cured 
some  desperate  cases  by  amputating  the  uterus  above  the  cervix,  and 
attaching  the  stump  in  the  peritoneal  wound.  Others  have  attached 
the  uterus  and  its  appendages  to  the  abdominal  walls  after  laparotomy 
for  other  purposes.  This  latter  method  would  hardly  be  attempted 
by  a  special  laparotomy,  as  there  would  be  too  much  uncertainty  of 
the  attachment  holding,  and  too  little  certainty  of  the  patient  recover- 
ing from  the  operation. 

Measures  to  Supplement  or  Restore  the  Pelvic  Floor  and  Perineal  Supports 

The  pelvic  floor  and  perineum  may  be  supplemented  or  restored 
for  the  retention  of  a  prolapsed  or  protruded  uterus  by  (1)  hystero- 
phores  or  pessaries,  and  (2)  by  plastic  operations. 


Hysterophores  or  Pessaries. 

The  simplest  yet  least  efficient  form  of  hysterophore  is  the  ordinary 
perineal  band,  passing  over  the  vulva  and  attached  to  an  abdominal 
supporter  or  broad  elastic  belt.     Its  most  useful  application  is  in  con- 


FlG.  239. 


Fitch  Supporter. 

nection  with  a  large  vaginal  tampon,  introduced  in  the  Sims  position, 
so  as  to  fill  the  replaced  vagina.  It  may  be  medicated  with  astrin- 
gents and  antiseptics,  such  as  tannin,  boracic  acid,  a  mixture  of  tannin 
and  iodoform,  persulphate  of  iron.  Fuller's  earth,  etc.,  and  may  be 
changed  once  in  two  or  three  days,  or  left  for  five  or  six  days,  i.  e.,  as 
long  as  it  remains  in  place  and  free  from  odor.  Some  patients  can  be 
taught  to  use  them  upon  themselves,  by  first  returning  the  protruded 


606 


DISPLACEMENTS    OF   THE   UTERUS. 


mass,  and  j)ushing  back  the  cervix  toward  the  sacrum,  or  b}^  assum- 
ing the  knee-chest  position,  and  then  stuffing  the  vagina  full. 

Hackenberg,  of  Rochester,  N.  Y.,  precedes  the  tampon  b}^  tannic 
acid.  The  uterus  is  pushed  as  far  up  as  practicable  by  the  speculum 
introduced  in  the  dorsal  position,  thirty  grains  of  the  tannin  placed 
around  the  cervix  and  dry  cotton  packed  in  the  vagina  after  it.     The 


Fig.  240. 


•CD'S  N><VW31tJ.9 


Silk  Elastic  Belt. 


advantage  of  thus  using  the  astringent  is  that  it  contracts  the  vagina 
instead  of  dilating  it,  as  do  pessaries  and  other  kinds  of  tampons.  Dr. 
Hackenberg  claims  to  have  made  permanent  cures  in  this  way. 

Strong  solutions  of  sulphuric  acid,  tannin,  acetate  of  lead,  decoctions 
of  oak  bark  or  other  astringent  solutions,  used  as  vaginal  injections, 
are  also  helpful  adjuvants  in  producing  contraction  of  the  vagina  and 
vulva. 

Such  procedures  are,  however,  not  so  often  curative  as  preparatory 
to  other  treatment.  They  contract  the  parts,  relieve  the  tension  upon 
the  uterine  supports,  promote  involution,  and  thus  bring  the  case 
within  the  reach  of  the  more  radical  treatment. 

The  soft  rubber  pessary  introduced  in  the  Sims  position,  or  in  the 
dorsal,  sometimes  exerts  a  beneficial  influence  upon  the  pelvic  organs 
when  they  are  congested  and  tender,  but  seldom  does  much  toward 
curing  the  prolapse,  as  it  keeps  the  vaginal  walls  distended  and  thus 
prevents  them  from  returning  to  a  natural  state. 

The  Peaslee,  Mayer,  or  Dumont-Pallier  elastic  ring  pessary,  covered 
with  soft  rubber,  is  often  a  good  temporary  exiDedient,  and  in  moderate 
cases  gives  great  comfort  to  the  patient  (Fig.  232).  It  does  not  require 
frequent  removal  for  cleansing,  as  does  the  soft  rubber  inflated  ring,  and 
may  be  left  in  place  for  weeks  at  a  time,  provided  an  antiseptic  vagi- 
nal douche  be  used  twice  a  day.  A  large  glycerine  or  astringent  tam- 
pon introduced  under  and  in  front  of  tbe  cervix  every  morning  and 
removed  at  night,  may  be  employed  by  the  patient  with  great  comfort 


HYSTEROPHORES    OR   PESSARIES. 


507 


and  benefit  while  slie  is  wearing  the  elastic  ring.  The  ring  must  often 
be  quite  large,  so  as  to  be  retained  by  the  bony  pelvic  walls.  It  then 
finds  a  rest  against  the  tuberosities  of  the  ischium  and  pubic  rami. 

A  rubber  bag  introduced  by  the  patient  in  the  knee-chest  position 
and  then  inflated  by  a  syringe,  or  a  collapsed  soft  rubber  ring  may  be 
similarly  employed. 

A  large  Hodge  pessary  may  be  used  for  prolapse  and  sometimes  for 
procidentia.  B.  L.  Schultze's  modification,  called  the  sleigh  pessary, 
forms,  however,  a  better  support  for  the  pelvic  roof,  and  will  often  be 
found  useful. 

Zwank's  pessary  (Fig.  242),  which  has  two  branches  resembling 
wings,  is  often  a  convenient  makeshift.  It  is  introduced  closed,  and 
then  expanded  until  the  wnngs  rest  on  the  ischial  tuberosities.  It 
keeps  the  parts  within  the  pelvis  and  gives  great  temporary  relief. 

Fig.  241.  Fig.  242. 


Schultze's  Sleigh  Pessary. 


Zwank's  Pessary. 


When  left  too  long  in  place  it  is  liable  to  cause  ulceration,  and  must, 
therefore,  be  carefully  watched  and  occasionally  removed.  This  incon- 
venience applies  to  nearly  all  pessaries  used  for  procidentia. 

Of  late  Breisky  has  brought  the  forgotten  egg  pessary  back  into  use. 

Scanzoni  attached  a  stem  with  a  ball  to  a  perineal  band  for  the  pur- 
pose of  holding  the  uterus  higher  in  the  pelvis.  The  Roser-Scanzoni 
hysterophore  is  an  improvement  upon  the  original,  and  has  been  ex- 
tensively used.  In  this  country  cups  and  rings  have  been  placed  on 
the  stem,  instead  of  the  ball  and  the  stem,  and  perineal  bands  have 
been  made  of  elastic  material  to  avoid  sudden  violence  during  muscu- 
lar exertion  of  the  patient,  or  ulceration  from  too  firm  pressure. 

Cutter  placed  a  cup  on  the  stem  to  support  the  cervix,  or  an  elon- 
gated ring  to  pass  into  the  posterior  fornix,  and  extended  the  stem  out 
over  the  perineum  and  back  between  the  nates  to  join  a  tape  or  rubber 
to  be  attached  to  a  waistband.  Thomas  has  improved  upon  the  origi- 
nal one  somewhat. 


608 


DISPLACEMENTS   OP  THE   UTERUS. 


Dr.  Scott,  of  Woodstock,  Canada,  constructs  a  pessary  of  about  the 
same  shape  as  Cutter's.     It  has  the  great  advantage,  however,  that  it 


Fig.  243. 


Mcintosh  Uterine  Supporter. 


Fig.  244. 


Mcintosh  Uiennt;  Supporter  Applied. 


can  be  made  by  any  physician  and  bent  to  suit  any  case.     Take  a 
piece  of  copper  wire  about  a  si5iteenth  of  an  inch  in  diameter  and  six- 


FiG.  245. 


Thomas's  Modified  Cutter  Pessary. 


teen  or  eighteen  inches  in  length.     SHp  a  piece  of  small  but  heavy 
rubber  tubing  upon  the  middle  third  of  it.     Bend  the  covered  portion 


Fig.  246. 


Fig.  247 


Scott's  Pessary. 


Pessary,  with  Tapes  for  Attachment  to  a  Belt. 
(Schematic) 


of  the  wire  into  a  ring,  so  that  the  ends  of  the  rubl>er  tubing  will  meet ; 
then  twist  the  ends  of  the  wire  into  a  stem  and  slip  another  piece  of 


PLASTIC  OPERATIONS  UPON  THE  PERINEUM  AND  PELVIC  FLOOR.    509 

tubing  over  the  twisted  stem.  The  junction  of  the  tubes  at  the  upper 
end  of  the  stem  may  be  consolidated  by  filling  the  uneven  edges  with 
cotton  batting,  winding  thread  around  it,  and  then  coating  it  with 
flexible  collodion.  Then  bend  the  ring  portion  into  an  oval  shape, 
with  a  curve  on  the  flat,  so  as  to  enable  it  to  reach  up  behind  the  cer- 
vix, and  bend  the  stem  sharply  back  at  a  point  about  an  inch  from 
the  lower  end  of  the  ring  and  give  it  the  curve  of  the  sacrum,  so  that 
it  will  pass  up  between  the  nates  toward  the  waist.  A  tape  attached 
to  the  end  of  the  wire  will  serve  to  fasten  it  to  a  strip  of  cloth  tied 
around  the  waist.  I  have  thus  frequently  made  the  Scott  pessary, 
and  have  taught  the  patient  to  introduce  it  before  rising  in  the  morn- 
ing and  to  remove  it  after  getting  into  bed  at  night.  She  must  be  told 
to  be  careful  in  getting  the  ring  behind  the  cervix,  i.  e.,  to  make  the 
ring  sweep  around  the  hollow  of  the  sacrum  instead  of  straight  up 
behind  the  pubes. 

In  some  of  the  instrument  stores,  particularly  in  New  York,  a  Scott 
pessary  is  made  of  hard  rubber  in  which  the  ring  is  prolonged  into 
the  vulval  portion,  or  to  a  point  where  the  stem  should  turn  back. 
In  case  of  simple  prolapse  or  retroversion,  when  the  vulva  is  not 
dilated,  this  prolongation  is  an  evident  disadvantage,  as  it  takes  up 
more  space  in  the  vulva,  and  is  liable  to  irritate. 

The  Priestly  and  Lazarevitsch  pessaries  in  the  foreign  market  are 
also  stem  pessaries. 

Plastic  Operations  upon  the  Perineum  or  Pelvic  Floor. 

Fricke,  of  Hamburg,  united  the  denuded  labia  (episiorrhaphy)  for 
the  retention  of  the  prolapsed  uterus  and  vagina  and  succeeded  in 
ameliorating  the  condition  of  some  of  his  cases  in  which  he  could  not 
fit  a  pessary.^  Gerardin,  of  Metz,  proposed  in  1823  to  denude  two 
opposite  surfaces  at  the  lower  end  of  the  vaginal  canal  and  unite 
them.t  Meude  proposed  the  formation  of  an  artificial  hymen.  Dief- 
fenbach  denuded  surfaces  on  the  lateral  vaginal  walls  a;nd  united 
them.     Malgaigne  made  denudations  higher  up. 

These  attempts  were  of  course  unsatisfactory  because  they  merely 
converted  a  procidentia  into  a  prolapse  or  lapse.  Simon  was  the  first 
to  attempt  to  hold  the  uterus  at  its  normal  elevation  in  the  pelvis  by 
narrowing  the  vagina.  Fig.  248  shows  the  original  Simon  denudation 
and  the  various  modifications  since  employed  for  prolapse,  and  which 
have  been  referred  to  under  the  chapter  on  Perineorrhaphy.  To  these 
may  be  added  those  of  FritschJ  and  Reamy,§  which  will  be  under- 
stood by  an  examination  of  Figs.  249  and  250. 

*  Lageveraenderungen,  etc.,  des  Uterus.     Fritsch. 

t  Lehrbuch  der  Frauenkrankheiten.     Winckel. 

X  Op.  cit.  I  Medical  News,  April  9,  1887. 


510 


DISPLACEMENTS    OF   THE    UTERUS. 


Hegar's  is  the  best  of  the  median  operations.     It  forms  an  un- 
naturally large  perineal  triangle  and  a  high,  long  recto- vaginal  pro- 


FlG.  248. 


Outlines  of  Denudation  for  Procidentia.    After  Winckel. 

montory.     Martin's  is  the  best  of  the  bilateral  operations.     None  of 
them,  however,  are  suited  to  the  child-bearing  woman.     One  of  the 


Fio.  249. 


Fig.  2.'n. 


Denudation  for  Procidentia.    After  Fritsch. 


aaxus 

Denudation  for  Procidentia.    After  Reair.v. 


TREATMENT    OF    VEESIOXS.  511 

other  operations  described  in  the  chapter  on  Perineorrhaphy  would 
be  preferable  as  forming  less  obstruction  during  a  subsequent  labor. 

Choice  of  Methods. 

As  the  object  to  be  accomplished  in  the  management  of  prolapse 
and  procidentia  is  not  merely  to  push  the  parts  back  from  the  vulva, 
but  to  restore  the  normal  condition  and  relationship  of  the  pelvic,  and 
to  a  certain  extent  the  abdominal  viscera,  a  combination  of  the  dif- 
ferent procedures  already  recommended  will  usually  be  necessary. 
When  the  causative  condition  is  found,  that,  of  course,  should  receive 
the  first  attention. 

NuUiparous  cases  should  if  possible  be  treated  without  any  mutila- 
tion of  the  vulva  and  vagina.  Uterine  enlargement  in  the  subacute 
or  progressive  stage  should  be  treated  with  remedies  designed  to  re- 
move all  congestion  and  inflammation,  and  the  organ  supported  by 
vaginal  tamponment  or  packing.  Chronic  subinvolution,  hyperplasia 
or  elongation  of  the  cervix  must,  when  present,  receive  separate  treat- 
ment before  the  uterus  can  be  jDcrmanently  replaced. 

The  strengthening  of  the  supports  by  astringent  vaginal  and  rectal 
injections,  and  the  simultaneous  or  subsequent  use  of  tampons  and 
pessaries  should  also  be  thoroughly  tried.  If  these  be  not  sufficient, 
shortening  of  the  round  and  sacro-uterine  ligaments,*  or  both,  may  be 
employed  together  with  the  tampons  or  pessaries. 

When  the  patient  has  borne  children,  as  is  almost  always  the  case, 
we  should  look  for  injuries,  and  results  of  injuries,  in  parturition.  If 
we  find  a  laceration  of  the  pelvic  floor  or  perineum,  we  must  not,  how- 
ever, think  that  the  misplacement  will  necessarily  be  cured  when  that 
is  repaired.  The  same  attention  must  be  given  to  all  the  factors  as  in 
treating  nullipars,  and  all  congestions,  enlargements  and  subinvolu- 
tions of  the  genital  organs  reduced  as  far  as  possible,  that  they  may 
not  reproduce  the  difficult3^  The  operation  upon  the  perineum  and 
pelvic  floor  may  be  among  the  last  steps  in  the  cure.  Operations 
upon  the  pelvic  roof  structures  must  often  precede  them. 

When  rational  treatment  cannot  be  carried  out,  sometimes  Lefort's 
or  Neugebauer's  operation  combined  with  an  Alexander  operation 
may  be  performed,  and  the  patient  rendered  much  more  comfortable. 

Treatment  of  Versions. 
I.  Anteversion. 

Anteversion,  being  usually  symptomatic  of  contraction  or  pressure 
of  tissues  outside  of  the  uterus,  or  of  enlargement  about  the  fundus  or 
anterior  wall,  is  relieved  by  the  treatment  of  these  pathological  states. 

*  See  Treatment  of  Retroversions. 


612  DISPLACEMENTS   OF    THE   UTERUS. 

Vaginal  Tamponment 

Abdominal  or  vaginal  supports  should  be  used  as  soon  after  the 
causative  inflammatory  or  other  conditions  will  permit,  not  so  much 
for  the  purpose  of  replacing  the  uterus  as  to  relieve  the  traction  or 
pressure  upon  tender  or  indurated  places.  Hence  the  vaginal  tampon 
should  be  preferred  to  the  pessary,  which  is  apt  to  press  uncomfort- 
ably and  constantly  over  limited  areas.  The  tampons,  in  order  to 
relieve  the  tender  or  rigid  parts  of  the  weight  of  the  uterus  or  force  of 
abdominal  pressure,  must  sometimes  temporarily  favor  or  even  increase 
the  malposition.  Thus  if  sacro-uterine  ligaments  be  rigid  or  con- 
tracted, the  tampons  are  placed  under  and  in  front  of  the  cervix,  so  as 
to  keep  the  cervix  back,  and  up,  and  prevent  it  dragging  upon  them. 
They  may  thus  increase  the  version.  When,  however,  the  fundus  is 
pressed  down  by  abdominal  pressure  so  as  to  irritate  the  bladder  or 
painfully  twist  the  cervical  attachments,  then  the  corpus,  or  both 
corpus  and  cervix,  should  be  raised  to  a  position  of  comfort.  When 
the  round  ligaments  or  their  surrounding  tissues  are  tender  and  con- 
tracted, the  plugs  should  hold  the  cervix  and  fundus  in  the  position 
in  which  they  are  thus  drawn.  When  the  weight  of  only  a  part  of 
the  uterus  is  at  fault,  the  tampons  must,  of  course,  aid  in  supporting 
the  weighty  portion. 

Anteversion  Pessaries. 

When  the  deposits  and  contractions  have  been  removed,  then  the 
uterus  will  need  no  pessary  or  support  for  the  anteversion,  not  only 
because  the  anteversion  would  then  be  painless  and  harmless,  but 
because  the  anteversion  will  usually  cease  to  exist.  The  uterus  may 
return  to  a  normal  or,  what  is  usual,  pass  to  a  state  of  lapse,  prolapse, 
retroversion,  or  other  malposition,  and  thus  require  a  pessary  or  other 
treatment  for  its  new  position.  The  anteverted  uterus  is  usually 
hardened  and  heavy,  or  we  would  have  an  anteflexion  at  the  same 
time.  The  disappearance  of  the  disease  about  the  contracted  sacro- 
uterine or  round  ligaments  is  apt  to  be  followed  by  their  relaxation, 
and  a  consequent  movement  either  of  the  cervix  too  far  downward 
and  forward,  or  of  the  fundus  too  far  back.  A  lapse  or  prolapse 
follows  in  the  first  case,  while  a  retroversion  may  easily  be  produced 
in  either. 

When,  however,  a  pessary  is  used  it  should  be  used  on  the  same 
principles  as  the  tamponment,  viz.,  to  give  the  pelvic  organs  relief 
without  reference  to  the  malposition.  When  the  retention  of  the 
uterus  in  a  normal  position  gives  greatest  relief,  then,  and  not  until 
then,  should  it  be  so  held  by  a  pessary. 

In  this  country,  Gehrung  and  Thomas,  and  in  England,  Hewitt  have 
invented  the  most  popular  forms  of  anteversion  and  anteflexion  pes- 
saries.    Thomas  has  invented  several  varieties.     In  my  own  practice 


ANTEVERSION    PESSARIES. 


513 


I  utilize  my  own  model  of  retroversion  pessary  (see  Retroversion,  Fig. 
256),  by  bending  the  neck  or  collar  a  little  further  forward  than  for 
retroversion,  as  in  Fig.  254.  I  thus  can  make  it  support  the  cervix,  or 
lift  the  body,  as  much  or  as  little  as  desirable  by  altering  the  size, 
position,  and  shape  of  the  collar.     When  the  vesico-vaginal  septum  is 


Fig.  232. 


Gehrung"s  Pessary  for  Anteversion. 


Hewitt's  Anteversion  Pessary. 


firm,  it  does  not  reach  the  corpus,  but  pries  up  the  fundus  by  the 
traction  of  the  elevated  septum  upon  the  cervix  in  a  forward  direction. 
When  the  cervix  is  to  be  supported  merely,  a  small  sized  one  with  the 


Fig.  253. 


Fig.  254. 


"■'"«M^7w;-^5~- 


Thomas's  Anteversion  Pessary. 


Byford's  Pessary  with  tlie  Neck  Elevated 
for  the  Relief  of  Anteversion. 


retroversion  shape  may  be  used,  Fig.  256  or  257.  Thomas's  elastic 
soft  rubber  modification  of  the  Albert  Smith  pessary,  Avith  a  pad  for 
retroflexions.  Fig.  270,  can  often  be  satisfactorily  bent  into  this  shape. 
Sims's  operation  of  denuding  a  surface  in  front  of  the  cervix,  and 
another  a  little  lower  down  and  stitching  them  together,  so  as  to 
shorten  the  anterior  vaginal  wall,  is,  it  seems  to  me,  an  unscientific 
procedure  for  anteversion  or  anteflexion,  and  does  not  affect  the  parts 
involved  in  their  production  except  to  create  traction  upon  the  cervix. 
It  can  only  overcome  such  displacement  by  force.     Sims's  method  of 


614  DISPLACEMENTS    OF   THE    UTEEUS. 

denuding  the  anterior  lip,  and  uniting  it  to  the  anterior  vaginal  wall 
farther  down,  is  still  less  scientific. 

I  formerly  modified  the  Albert  Smith  retroversion  pessary  by  elon- 
gating the  tongue  or  anterior  end,  and  bringing  it  out  over  and  under 
the  perineum,  so  as  to  prevent  the  instrument  slipping  too  far  into  the 
vagina.  By  then  making  the  vaginal  jjortion  sufhciently  short,  it  held 
or  pried  the  lower  end  of  the  cervix  forward  and  corrected  the  malpo- 
sition.    At  the  point  where  the  bars  passed  through  the  vulva,  they 


Fig.  255. 


"S-e-ctitzni 


Anteversion  Pessary  acting  by  holding  the  Lower  End  of  the  Cervix  Forward. 

were  made  to  touch  each  other,  and  thus  occupy  but  little  space.  The 
discomfort  experienced  by  the  patient  from  having  the  cervix  thus 
dragged  forward,  led  me,  however,  to  abandon  such  treatment.  It 
corrected  the  misplacement,  but  often  increased  the  irritation,  which 
should  have  been  subdued. 

II.  Retroversion. 

The  treatment  for  retroversion  here  given  is  equally  applicable  to 
retroversion  with  slight  retroflexion. 

In  the  Acute  and  Subacute  Stages. 

Before  the  uterus  is  replaced,  acute  and  subacute  inflammatory  con- 
ditions should  be  removed.  When  the  uterus  and  vagina  become 
tolerant  of  cotton  tampons  medicated  with  glj^cerine,  they  may  be 
used  with  great  benefit.  At  first  it  is  better  to  place  a  soft  one  under 
the  cervix,  in  order  to  relieve  the  cervical  supports  of  the  strain,  which 
the  abdominal  pressure  bearing  upon  the  exposed  vesico-vaginal 
septum  must  occasion — particularly  so  in  the  standing  posture.  But 
the  tampon  should  not  be  pushed  back  in  the  fornix  so  as  to  press 
upon  tender  ovaries  or  retrouterine  tissues.  In  many  cases  the  con- 
tinuance of  localized  pelvic  inflammations  renders  all  other  mechanical 
support  than  this  impossible  for  a  long  time. 

Rejilacement. 

After  the  inflammation  has  subsided  an  attemi^t  may  be  made  at 
replacement.     This  is  done  by  pushing  the  cervix  back,  or  the  fundus 


ADHESIONS.  515 

upward,  or  both.  The  most  common  method  employed  is  to  introduce 
two  fingers  into  the  vagina  and  push  upward  against  the  fundus 
through  the  posterior  cul-de-sac  with  one,  and  backward  against  the 
cervix  with  the  other.  It  is  very  difficult  to  reach  far  enough  with  the 
finger  in  the  posterior  fornix  to  get  the  fundus  above  the  sacrum,  hence 
the  finger  against  the  cervix  has  to  do  the  jDrincipal  work.  I  usually 
find  it  more  efficacious  to  depend  entirely  upon  leverage,  and  accord- 
ingly press  the  middle  finger  in  the  vaginal  fornix  backward  under 
the  fundus  toward  the  lower  end  of  the  sacrum.  The  posterior  vaginal 
wall  is  thus  made  to  draiv  the  upper  end  of  the  cervix  back,  while  the 
forefinger  pushes  back  the  lower  end.  After  the  cervix  is  well  back 
the  other  hand  over  the  abdomen  should,  if  joossible,  be  caught  over 
the  fundus  and  be  used  to  pull  it  down  over  the  pubes,  and  complete 
the  replacement.  Sometimes  two  fingers  in  the  rectum  may  be  used 
to  press  up  the  fundus,  and  the  thumb  of  the  same  hand  in  the  vagina 
to  push  back  the  cervix. 

Another  method  of  replacement,  advocated  by  Campbell,*  is  to  put 
the  patient  in  the  knee-chest  position  and  admit  air  to  the  vagina.  If 
the  fundus  is  not  immediately  drawn  up  into  the  abdomen  it  may  be 
pushed  out  of  the  hollow  of  the  sacrum  by  the  fingers  or  by  any  thick 
blunt  instrument. 

In  case  the  vaginal  portion  of  the  cervix  is  too  short  or  soft  to  afford 
any  leverage,  or  the  uterus  too  flabby  to  be  forced  or  pushed  up,  I 
sometimes  introduce  a  stem  probe,  which  is  practically  the  same  as  a 
hard  stem  pessary  (Fig.  269)  and  then  am  not  only  able  to  replace  the 
uterus  by  leverage,  but  can  tell  by  the  position  of  the  lever  end  of  the 
stem  just  where  the  fundus  has  gone  to.  This  method  is  valuable  in 
determining  the  presence  or  extent  of  adhesions,  and  is  much  less 
severe  upon  some  patients  than  the  bimanual.  Some  gynecologists 
use  the  probe  or  an  intrauterine  repositor  for  the  purpose  of  reposit- 
ing  the  fundus.  Such  methods  are  more  hazardous  for  any  but  the 
experienced  to  employ,  and  are  seldom  a  necessity. 

Adhesions. 

When  the  uterus  cannot  be  thus  replaced,  or  when  the  fundus  will 
rise  only  a  certain  distance  before  encountering  firm  resistance,  or 
causing  the  patient  great  pain,  it  is  probably  held  by  adhesions. 

Adhesions  are  of  two  kinds,  viz:  (1)  direct  adhesions  between  the 
peritoneal  surfaces  of  the  uterus  and  its  appendages  to  their  surround- 
ings, and  (2)  indirect  adhesions,  as  cicatrices  or  contractions  in  the 
cellular  tissue  about  the  uterus  preventing  it  from  returning  to  a 
normal  position.  Both  kinds  may  sometimes  be  overcome,  especially 
if  recent,  by  treatment  directed  to  the  absorption  of  the  abnormal 

*  Transactions  American  Gyn.  Soc,  vol.  i. 


516  DISPLACEMENTS   OF   THE   UTERUS. 

tissues.  In  the  chronic  stage  the  first  may  be  materially  influenced 
and  sometimes  overcome  by  intermittent  or  constant  traction,  while 
the  second  kind  are  only  slightly  benefited  thereby. 

The  Vaginal  Pack. 

In  the  subacute  and  chronic  stages  of  the  inflammation  producing 
the  adhesions,  and  after  the  pelvic  tissues  will  tolerate  moderate  pres- 
sure, the  retroversion  is  benefited  by  the  vaginal  pack  or  tamponment. 
We  then  no  longer  rely  on  the  mere  cervical  support  of  a  glycerine 
plug,  but  we  pack  the  posterior  and  lateral  fornices  with  antiseptic 
cotton  so  as  to  support  the  whole  organ.  The  cervix  is  not  merely 
pushed  back  and  tamponed  there,  for  that  would  tend  to  increase 
whatever  flexion  or  tendency  to  flexion  might  exist,  and  create  dis- 
comfort, but  the  fundus  is  pushed  well  up,  and  the  posterior  fornix 
filled  with  two  or  three  dry  pieces  of  wool  or  cotton  (not  the  absor- 
bent). Then,  if  there  be  room,  a  small  flat  tampon  saturated  with 
glycerine  or  oil  is  placed  on  each  side  of  the  cervix,  a  larger  one  under 
it  and  perhaps  one  in  front.  The  vaginal  entrance  should,  however, 
be  free  of  all  packing  or  pressure. 

When  the  uterus  is  quite  movable  the  packing  may  be  more  advan- 
tageously placed  in  the  knee-chest  position.  The  fundus  and  ovaries 
will  then  be  out  of  the  way  during  the  packing  and  will  settle  on  the 
pack  more  comfortably. 

The  first  packing  should  be  loose  and  small,  and  should  not  distend 
the  vagina,  nor  should  subsequent  ones  ever  be  so  large  as  to  cause 
discomfort.  Engleman"^  uses  medicated  cotton  for  the  purpose  of 
getting  a  medicinal  effect  upon  the  pelvic  organs  as  well. 

When  the  fundus  can  be  replaced  by  the  knee-chest  position  the 
pack  should  be  so  arranged  as  to  hold  the  cervix  well  back  and  thus 
retain  the  organ  in  as  normal  a  position  as  possible. 

If  properly  placed  it  may  remain  from  two  to  five  or  six  days.  If 
any  tendency  to  irritation  or  ulceration  due  to  the  packing  be  discov- 
ered the  cotton  or  wool  should  be  lubricated  and  should  not  be  re- 
newed for  a  day  or  two  after  being  removed. 

Breaking  Up  of  Adhesions. 

B.  S.  Schultze  f  recommends  the  breaking  up  of  adhesions  under 
chloroform  narcosis.  He  introduces  two  fingers  into  the  rectum  and 
the  thumb  into  the  vagina,  and  after  repositing  the  uterus  sufficiently 
to  put  the  band  of  adhesions  on  the  stretch,  breaks  them  slowly  by 
hooking  the  rectal  fingers  over  them.  Flat  adhesions  are  separated  by 
the  rectal  finger  as  the  placenta  would  be  separated  from  the  uterine 


*  American  Journal  of  Obsteti-ics,  June,  1887. 
f  Op.  cit. 


MECHAISIICAL,   SUPPORT.  517 

wall.  Flat  adhesions  of  the  uterus  to  the  rectum  are  often  difficult  to 
separate  because  the  rectum  ma}^  be  drawn  forward  with  the  uterus. 
Adhesions  of  the  tube  and  ovaries  to  the  sacrum  require  delicate 
handling  and  should  be  separated  by  a  slowly  increasing  pressure. 
Usually  they  cannot,  with  a  safe  amount  of  pressure,  be  separated  at 
one  sitting,  but  may  be  tried  again,  provided  no  reaction  follows  the 
first  trial. 

In  subacute  cases  we  may  usually  get  the  uterus  free  by  treatment 
directed  to  the  absorption  of  the  plastic  deposits.  In  chronic  cases  I 
have  for  weeks,  and  sometimes  months,  employed  vaginal  and  bi- 
manual manipulation  once  or  twice  a  week  to  break  up  the  adhesions. 
By  sweeping  the  vaginal  finger-end  from  side  to  side  between  the  ad- 
herent rectum  and  uterus,  and  drawing  up  the  uterus  until  the  pain 
became  quite  severe,  I  have  usually  succeeded  in  freeing  the  fundus 
so  that  it  could  be  lifted  up  but  not  always  forward.  The  difficulty 
is  that  when  the  patient  can  endure  such  manipulations  the  adhesions 
are  too  chronic  to  be  completely  sejjarated  in  this  way.  I  have  also 
partly  liberated  ovaries  and  tubes,  and  have,  by  no  other  treatment 
than  this,  supplemented  by  a  glycerine  tampon  and  the  vaginal  douche, 
caused  all  dysmenorrhoea  and  pelvic  symptoms  to  disappear,  together 
with  the  cervical  ulceration  and  congestion.  But  the  vast  majority 
of  cases  that  come  to  me  require  a  long  course  of  treatment  before  such 
manipulations  can  be  tolerated. 

Recently  Polk  *  has  recommended  and  performed  laparotomy  for 
the  purpose  of  breaking  up  the  adhesions  in  old,  obstinate  cases, 
accompanied  by  great  suffering,  and  has  succeeded  in  relieving 
the  symptoms.  In  case  the  uterus  requires  support,  he  follows  the 
laparotomy  by  an  Alexander-Adams  operation.  I  prefer  making  a 
vaginal  incision  into  the  recto-uterine  pouch,  and  breaking  them  up 
through  that.  I  have  done  so  in  four  cases,  but  have  each  time  found 
it  advisable  to  remove  the  diseased  ovaries  and  tubes  at  the  same  time. 
In  the  last  two  cases  I  held  the  uterus  in  place  by  vaginal  tampons, 
and  thus  cured  the  displacements. 

Mechanical  Support. 

After  all  inflammatory  reaction  and  obstructing  adhesions  or  con- 
tractions have  been  removed  from  the  pelvic  tissue,  the  uterus  has  a 
tendency  to  return  to  its  normal  position.  Many  times,  however,  the 
sacro-uterine  and  round  ligaments  remain  relaxed  and  weakened,  and 
have  not  the  power  of  turning  the  fundus  forward  after  an  evacuation 
of  the  bladder,  or  of  preventing  a  backward  displacement  during 
straining  in  a  stooping  posture,  as  in  defecation,  lifting,  etc.  It  may 
be  reiterated  here  that  during  muscular  exertion  a  greater  strain  is 

*  American  Journal  of  Obstetrics,  June,  1881. 


518  DISPLACEMENTS    OF    THE   UTERUS. 

often  thrown  upon  the  uterus  than  its  suspensory  supports  can  bear 
(crowding  it  down  against  the  pelvic  floor),  while  during  muscular 
relaxation  but  little  power  is  required  to  return  and  hold  it  in  a  nor- 
mal position. 

As  a  consequence,  much  advantage  will  be  gained  by  supporting 
the  uterus  until  stretched  ligaments  have  become  retracted,  and  any 
chronic  indurations  or  cicatrizations  sufficiently  absorbed  or  stretched 
to  allow  the  corpus  uteri  to  incline  over  the  bladder  without  restraint. 
Mechanical  supports  or  pessaries  accomplish  this  by  taking  advantage 
of  the  pivot  or  ball-and-socket  action  of  the  cervical  supports,  and  pry 
the  fundus  forward  by  turning  the  cervix  backward.  They  may  be 
divided  into  four  classes :  (1)  those  acting  in  front  of  the  cervix  by 
keeping  it  in  the  back  part  of  the  pelvis  ;  (2)  those  acting  behind  the 
cervix  by  drawing  the  cervix  backward;  (3)  those  combining  the 
action  of  both  of  the  above  methods,  and  (4)  those  acting  similarly 
upon  the  cervix  within  its  canal. 

Pessaries  Acting  in  Front  of  the  Cervix,  or  Barrier  Pessaries. 

The  advantages  of  pessaries  acting  in  front  of  the  cervix  are  that 
they  interfere  but  little  with  the  natural  uterine  supports,  restrict  but 
slightly  the  normal  motions  of  the  uterus,  and  can  be  removed  and 
introduced  by  the  patient. 

The  great  disadvantage  of  this  form  of  instrument  is  that  it  requires 
the  fundus  to  rest  without  restraint  in  front  of  the  sujjerior  strait  so  as 
to  receive  the  abdominal  pressure  upon  its  posterior  surface.  When 
from  lateral  or  other  traction,  or  retroflexion,  the  fundus  does  not  re- 
main well  forward,  abdominal  pressure,  which  at  times  is  all-powerful, 
will  turn  the  fundus  back  and  either  pry  the  cervix  over  the  barrier,  or 
else  pry  up  the  barrier  out  of  place.  A  short  vaginal  portion  of  the 
cervix,  short  anterior  vaginal  wall,  a  flabby  uterus,  tenderness  in  front 
of  the  cervix,  are  also  not  uncommon  conditions  that  limit  its  useful- 
ness. These  barrier-pessaries,  therefore,  find  their  chief  use  after  other 
more  powerful  supports  have  been  used,  and  it  has  become  desirable 
to  partly  withdraw  the  artificial  support  and  allow  the  uterine  liga- 
ments to  assume  function.  They  supplement  but  do  not  supplant  the 
ligaments  as  do  the  firmer  supports.  They  are  especially  useful  after 
labor,  at  which  time  the  size  of  the  uterus  affords  them  greater  advan- 
tage. In  case  of  laceration  of  the  cervix  they  should  especially  be 
tried,  as  they  both  lift  the  cervix  from  the  posterior  vaginal  wall  and 
hold  the  torn  lips  together. 

On  account  of  the  possibility  of  a  retroversion  occurring  while  they 
are  apparently  in  proper  place,  the  patient  should  assume  the  knee- 
chest  position  two  or  three  times  in  twenty-four  hours  and  admit  air 
to  the  vagina,  and  thus  replace  both  uterus  and  pessary  in  case  they 
should  be  displaced. 


BARRIER   PESSARIES. 


519 


The  simplest  form  of  the  barrier  pessary  is  a  piece  of  ordinary  cotton 
loosely  rolled  in  the  shape  of  a  spool  of  thread,  and  introduced  over 
and  behind  the  rectal  promontory,  in  front  of  the  replaced  cervix.  It 
should  be  changed  once  in  twenty-four  or  forty-eight  hours,  when  an 
antiseptic  vaginal  douche  may  be  used.  Having  been  thus  used  for 
a  time  it  may  be  removed  at  night  and  another  introduced  in  the 
morning.  The  patient  may  even  learn  to  introduce  it  herself  in  the 
knee-chest  position ;  or  in  the  knee-elbow  position  after  having  thus 
replaced  the  uterus.  She  can  of  course  remove  it  by  first  attaching  a 
string  to  it. 

Similarly  a  collapsed  rubber  ring  may  be  introduced  by  the  patient 
in  the  knee-elbow  position  after  thus  replacing  the  uterus,  and  then 
inflated. 

Courty's  barrier  pessary  consists  of  two  bars  resting  on  the  pelvic 
floor,  joined  in  front  where  they  impinge  against  the  pubes  or  vaginal 
entrance  by  a  cross  bar,  and  curved  up  posteriorly  around  either  side 
of  the  cervix  so  as  to  meet  in  front  of  it.     The  neck  thus  made  for  the 


Fig.  256. 


Fig.  257. 


Byford's  Retroversion  Pessary. 


Byford's  Retroversion  and  Prolapse  Pessary. 


cervix  forms  a  rigid  barrier  to  keej^  it  back.  Dr.  T.  D.  Fitch  of  this 
city,  without  having  seen  Courty's  instrument,  invented,  during  an 
extended  series  of  experiments,  an  instrument  similar  to  it. 

By  turning  the  posterior  end  of  an  Albert  Smith  in  front  of  the  cer- 
vix I  devised  an  instrument  which,  although  I  did  not  know  of 
Courty's  pessary,  was  practically  a  modification  of  it  (Fig.  256).  The 
difference  lay  in  the  tongue  shape  of  the  anterior  end,  the  curving  of 
the  bars  to  correspond  to  the  posterior  vaginal  wall  or  (if  that  were 
relaxed)  the  pelvic  floor,  and  the  depression  of  the  middle  portion  of 
the  collar  for  the  reception  of  the  cervix.  The  consequent  action  of 
the  pessary  is  elastic,  for  a  slight  rocking  motion  is  allowed  by  the 
curved  arms.  Where  there  is  danger  of  the  pessary  slipping,  the  arms 
may  be  separated  and  the  tongue  curved  back  under  the  pubes,  as  in 
Fig.  257.     Fig.  258  shows  the  pessary  in  place. 

It  may  be  introduced  turned  sideways  or  upside  down,  or  any  way 
in  which  it  enters  best,  until  the  collar  passes  behind  the  pubes,  and 


620 


DISPLACEMENTS    OF   THE    UTERUS. 


then  turned  right  side  up.  The  patient  can  easily  place  it  by  intro- 
ducing it  far  enough  for  the  collar  to  rest  behind  the  pubes,  and  then 
assuming  the  knee-chest  position  and  allowing  it  to  slip  into  position. 
She  can  remove  it  by  turning  it  partly  around  and  giving  it  a  little 
twist  as  she  withdraws  it,  or  by  turning  it  upside  down  and  rolling  or 
prying  it  out.  On  account  of  the  difficulty  in  altering  the  arms  so  as 
to  fit  the  posterior  vaginal  wall  in  the  hard  rubber  instrument,  I  have 
so  far  made  my  instruments  out  of  the  soft  rubber,  elastic,  Thomas 
and  Albert  Smith  pessaries  or,  when  a  large  one  was  required,  out  of 
the  largest  size  ring  of  cojDper  wire  covered  with  soft  rubber,  as  found 
in  the  shops. 

Fig.  258. 


Byford's  Retroversion  Pessary  in  Place. 


By  depressing  the  collar  the  barrier  may  be  placed  in  front  of  the 
lower  end  of  the  cervix  and  get  a  powerful  leverage  upon  the  fundus ; 
by  raising  the  collar  the  barrier  holds  the  whole  cervix  back,  but  gets 
less  of  the  leverage  power.  The  straighter  the  arms  the  less  is  the 
rocking  motion  and  the  firmer  and  more  rigid  the  barrier.  During 
defecation  it  is  always  advisable  for  the  patient  to  press  the  finger 
against  the  end  of  the  pessary  and  prevent  its  coming  forward,  and  to 
assume  the  knee-chest  position  afterward. 

I  have  had  better  success  in  permanently  curing  retroversions  with 


TRACTION    PESSARIES. 


521 


this  pessary  than  with  any  other.  Its  inefficiency  in  many  cases  is  in 
accord  with  its  non-interference  with  uterine  motion,  for  it  allows  the 
uterine  ligaments  to  resume  healthy  motion. 


Pessaries  acting  behind  the  Cervix,  or  Traction  Pessaries. 

The  advantages  of  the  pessaries  acting  behind  the  cervix  are  that 
they  take  a  firm  hold  upon  the  posterior  vaginal  wall,  and  draw  the 
cervix  up  as  well  as  back,  and  thus  prevent  ordinary  abdominal 
pressure  from  bearing  ujDon  the  anterior  uterine  wall  and  reproducing 
the  displacement.  Contractions  beside  the  uterus  which  prevent  the 
barrier  pessaries  from  acting  efficiently,  have  but  little  effect  in  repro- 


FlG.  259. 


Fig.  260. 


The  Albert  Smith  Retroversion  Pessary. 


Hodge's  Closed  Lever  Pessary. 


ducing  the  displacement  when  the  traction  pessaries  are  used  because 
of  the  firm  elevation  of  the  cervix.  Another  advantage  is  their  me- 
chanical simplicity,  and  the  ease  with  which  they  can  be  successfully 
used  by  the  general  practitioner. 

Their  disadvantages  are  that  they  are  apt,  by  distending  the  vagina, 
to  weaken  the  pelvic  roof ;  they  draw  the  cervix  higher  than  natural 
and  thus  interfere  with  the  normal  action  of  the  supports ;  they  are 
apt  to  retrovert  the  uterus  when  removed  by  the  patient,  and  they 
cannot  be  replaced  by  the  patient.  In  proportion  as  they  are  modified 
to  lessen  these  disadvantages  they  become  either  less  efficient  or  more 
difficult  of  adjustment.  They  are,  however,  and  will  probably  remain 
the  most  generally  useful  pessaries  for  retroversion. 

The  Hodge  closed  lever  pessary  is  the  oldest  and  most  efficient  of 
the  almost  infinite  varieties  to  be  found  in  the  shops.  It  consists  of 
an  elongated  ring  bent  somewhat  abruptly  upward  behind  the  cervix, 
and  more  gently  upward  in  front,  so  as  to  impinge  against  the  ante- 
rior vaginal  wall  behind  the  pubes.     It  is  liable  to  turn  in  a  roomy 


522  DISPLACEMENTS    OF   THE    UTEEUS. 

vagina  and  to  find  inefficient  support  against  a  relaxed  vesico-vaginal 
septum.  These  disadvantages  have  been  overcome  in  the  Albert 
Smith  pessary  by  narrowing  the  anterior  end  of  the  ring,  and  turning 
it  down  so  as  to  project  slightly  under  the  pubic  arch.  An  increase 
in  the  curve  of  the  arms  elevates  the  cervix,  increases  the  anteversion, 
and  renders  the  pessary  mechanically  more  efficient.  A  separation  of 
the  bars  diminishes  the  tendency  to  turn  sideways  and  slip  out  at  the 
vulva. 

As  an  excessive  elevation  of  the  cervix  is  unnatural  and  often 
harmful  and  unbearable,  Emmet  diminishes  the  length  and  abrupt- 
ness of  the  posterior  upward  curve.  He  also  employs  a  larger  bar 
than  others.     Hewitt's  retroversion  pessary  is   simply  an  elongated 


Fig.  261. 


Hewitt's  Cradle  Pessary. 

ring  with  a  gentle  curve  on  the  flat.  It  is  particularly  useful  when 
the  vagina  is  small,  but  it  is  liable  to  press  injuriously  behind  the 
pubes.  Schultze's  sleigh  pessary  is  a  modification  well  adapted  to  a 
relaxed  vagina.     (See  Fig.  241.) 

The  Scott,  Thomas,  Cutter,  Priestly,  and  Lazarewitsch  pessaries 
with  external  supports  are  also  valuable  when  the  relaxed  vagina 
does  not  retain  the  other  forms.  (See  Figs.  245,  246.)  Hanks,  Noege- 
rath,  Schroeder,  Gehrung,  and  others  have  devised  other  slight  modi- 
fications. 

The  ordinary  material  for  such  pessaries  is  the  hard  rubber.  The 
Albert  Smith  pessary  is  made  also  of  spring  wire  covered  with  soft 
rubber,  and  constitutes  an  excellent  instrument  for  the  general  prac- 
titioner. Any  form,  however,  may  be  given  to  the  copper  wire  rings 
covered  with  soft  rubber,  and  after  a  thorough  and  satisfactory  trial 
may  be  reproduced  by  the  instrument  dealer,  in  hard  rubber. 

Pessaries  Acting  both  in  Front  and  Behind  the  Cervix. 

The  advantages  of  pessaries  acting  both  in  front  and  behind  the 
cervix,  are  a  firmer  grasp  of  the  cervix,  and  a  dividing  of  the  force 
between  the  traction  and  pressure.  They  are  particularly  applicable 
when  the  posterior  vaginal  wall  is  relaxed  and  voluminous,  or  when 
the  cervix  is  lacerated.     The  disadvantages  are  an  unnatural  confine- 


PESSAEIES    ACTING    WITHIN   THE    CERVICAL    CANAL.  523 

ment  of  the  cervix,  difficulty  of  adjustment,  and  a  tendency  to  injuri- 
ous pressure. 

Fritsch  places  a  bar  (which  projects  slightly  upward)  across  a 
Hoclge  pessary  at  about  the  junction  of  the  posterior  and  "middle 
third. 

Studley,  and  T.  D.  Fitch,  place  a  ring  on  a  Hodge  or  Albert  Smith 
pessary,  so  as  to  project  forward  from  the  posterior  upper  end  and 
encircle  the  cervix. 

Schultze  twists  an  elongated  ring  into  a  figure  eight,  the  upper  or 
cervical  end  of  which  is  a  little  smaller  than  the  lower.  He  then 
curves  the  upper  ring  slightly  on  the  flat  so  that  the  concavity  looks 
upward,  and  the  lower  so  that  the  concavity  looks  downward;  or 
gives  it  any  special  curve  that  the  case  may  require.  The  cervix  rests 
in  the  upper  ring.  Objection  has  been  made  to  the  pessary  on  account 
of  its  interference  with  copulation.     I  have  not  used  it. 

Thomas  places  a  semicircular  bar  upon  the  upper  half  of  an 
Albert  Smith  pessary,  and  thus  gets  an   anterior  bearing  upon  the 

Fig.  262.  Fig.  263. 


Thomas's  Retroflexion  Pessary.  Fowler  e,  i'e&E,iii  > . 

Cervix  without  confining  it  as  much  as  those  just  mentioned.     When 
the  cervix  is  flabby  or  lacerated,  this  form  is  often  very  useful. 

The  Fowler  pessary  has  a  circular  opening  for  the  cervix,  and  is 
otherwise  thick  and  solid,  excepting  a  small  hole  in  the  tongue  in 
front.  It  is  very  much  the  shape  of  a  cadet  cap  turned  upside  down, 
and  rocks  upon  the  posterior  vaginal  walls,  as  do  the  others. 

Pessaries  Acting  within  the  Cervical  Canal. 

Retroversion  and  retroflexion  pessaries  acting  within  the  cervical 
canal,  are  usually  of  the  Albert  Smith  or  Hodge  variety,  with  an 
intrauterine  stem  attached  to  a  cross  bar,  or  resting  in  a  cup  or  sup- 
port. 

The  only  true  pessary  of  this  kind  with  which  I  am  acquainted,  is 
one  invented  by  H.  Marion  Sims.*  There  is  no  projection  into  the 
posterior  fornix,  but  the  stem  is  attached  to  the  posterior  end  or  cross 
bar,  and  moves  forward  and  backw^ard  on  it  as  a  pivot.     He  intro- 

*  American  Journal  of  Obstetrics,  June,  1886. 


524 


DISPLACEMENTS    OF    THE   TTEEUS. 


duces  it  in  the  Sims's  position.  When  the  stem  is  in  the  uterus,  it 
carries  the  cervix  back  and  tilts  the  fundus  forward  as  the  ring  is 
pushed  into  place  in  the  vagina.  The  Byrne,  Thomas,  and  Kinlock 
instruments  have  the  posterior  projection  of  the  Hodge  or  retraction 
pessaries,  and  are  therefore  a  combination  of  both  varieties. 

Fig.  264. 


H.  Marion  Sims's  Retroversion  Stem  Pessarv. 


Those  in  which  the  stem  has  a  hinge,  or  ball-and-socket  motion  upon 
the  cross  bar,  are  safer  and  hence  preferable  to  those  in  which  the  stem 
is  fixed  firmly  upon  the  cross  bar. 

The  advantages  of  this  form  of  pessary  are  those  that  belong  to  the 
uterine  stem  (see  Treatment  of  Flexions,  and  of  Dysmenorrhoea),  and 
which  aid  in  making  the  cure  of  the  replacement  permanent. 

The  disadvantages  are  the  great  danger  of  the  use  of  the  intra- 
uterine stem  in  general,  and  of  the  application  of  the  force  by  so  small 
a  rod. 

Since  writing  the  above  description,  I  have  learned*  that  Dr.  S.  J.  Donaldson,  of 
New  York,  had  used  a  similar  instrument  about  three  years  before  Dr.  Sims,  but  with- 
out his  knowledge. 


*  American  Journal  of  Obstetrics,  August,  1887. 


CHAPTER    XXXL 

DISPLACEMENTS  OF  THE  UTERUS  {Continued). 

Operative  Procedures  for  Retroversion. 

Operative  measures  for  the  relief  of  retroversion  are  (1)  for  the  pur- 
pose of  restoring  the  uterus  to  its  natural  condition,  (2)  of  restoring 
the  function  of  the  uterine  supports,  and  (3)  of  holding  the  fundus 
forward  or  the  cervix  backward  (operations  of  expedience.) 

To  Restore  the  Uterus  to  its  Natural  Condition. 

Enlargements  of  the  uterus  and  cervix  may  be  treated  by  the  same 
operations  as  already  recommended  for  prolapse  and  procidentia. 

To  Restore  the  Function  of  the  Uterine  Supports. 

Not  only  are  the  sacro-uterine  and  round  ligaments  the  ones  which 
prevent  retroversion  and  replace  the  temporarily  retroverted  uterus, 
but  they  are  the  ones  always  found  relaxed  or  elongated.  Therefore 
the  shortening  of  these  ligaments  may  be  resorted  to  as  a  cure  for 
the  misplacement. 

Shortening  of  the  Sacrouterine  Ligaments. 

I  have  so  far  only  attempted  to  shorten  the  sacrouterine  ligaments 
in  two  cases,  but  obtained  such  satisfactory  results  in  one  case  that  I 
consider  the  subject  worthy  of  farther  study.  The  following  is  the 
method  that  was  employed.  With  a  pair  of  small  tenaculum  forceps 
I  drew  the  cervix  forward  until  I  could  feel  the  somewhat  tense  sacro- 
uterine ligaments  by  a  finger  of  the  other  hand.  An  assistant  then 
held  the  forceps  while  I  introduced  a  stitch,  by  the  aid  of  the  touch, 
along  the  sacrouterine  ligament  so  as  to  grasp  an  inch  or  more  of  it. 
In  order  to  accomplish  this  I  used  a  long  heavy  needle  slightly  curved 
from  eye  to  point,  and  sharpened  only  about  the  point.^  It  was  grasped 
in  Fritsch's  needle  holder  so  that  the  chord  of  the  arc  formed  by  the 
needle  was  almost  parallel  with  the  long  axis  of  the  holder  (Fig.  265). 
Some  difficulty  was  experienced,  for  the  needle  point  had  to  be  intro- 
duced into  the  vaginal  covering  of  the  cervix  just  below  the  attach- 
ment of  one  of  the  ligaments,  carried  up  to  the  ligament  and  then 
backward  along  the  ligament  (as  felt  upon  the  finger)  into  the  back 

*  A  round  point  requires  too  much  force  to  push  it  through  the  connective  tissue. 
I  bent  one  the  first  time  I  tried  it. 


526 


DISPLACEMENTS   OF  THE   UTERUS. 


part  of  the  pelvis.  After  carrying  the  point  as  far  back  as  the  finger 
can  follow,  the  traction  upon  the  cervix  was  removed  and  the  posterior 
vaginal  wall  pushed  back  as  far  as  possible,  so  that  the  needle  when 
brought  through  it  would  include  as  little  vaginal  wall  as  might  be. 


Fig.  265. 


Needle  Mounted  upon  Fritsch's  Needle-holder  for  Introducing  Sutures  into  the  Sacrouterine 

Ligaments. 

So  far  I  have  merely  tied  the  stitch  about  the  puckered  vaginal  wall 
that  is  included.  Had  I  not  done  them  as  secondary  to  another 
operation  and  been  fearful  of  interfering  with  the  main  operation,  I 
should  either  have  excised  a  fold  of  the  vaginal  wall  between  the 
entrance  and  exit  of  the  needle,  or  should  have  made  a  vaginal  in- 
cision along  the  track  of  the  sutures,  from  each  stitch  hole  a  third  of 
the  way  to  the  other  into  which  a  part  of  the  suture  would  have 
sunk.  In  the  first  case  I  used  silkworm  gut,  in  the  second  catgut, 
and  obtained  the  best  results  with  the  former.  In  each  case  there  was 
a  lacerated  perineum,  and  relaxation  of  all  the  uterine  supports,  so 
that  but  for  a  cicatricial  contraction  in  the  left  broad  ligament,  the 
cervix  would  have  come  through  the  vulva.  In  each  instance  I  short- 
ened only  the  right  sacrouterine  ligament,  or  that  upon  the  side  opj^o- 
site  the  cicatricial  contraction.  A  cotton  tampon  was  placed  in  front 
of  the  cervix,  removed  each  day  for  a  vaginal  douche  to  be  given,  and 
then  another  tampon  introduced. 

In  the  case  in  which  I  used  the  silkworm  gut  the  cervix  is  now 
held  higher  from  the  pelvic  floor  than  normal,  when  the  pessary 
(which  she  still  wears)  is  removed.  Although  six  months  have  elaj^sed 
I  have  not  removed  the  pessary  except  temporarily  because  she  has 
been  obliged  to  carry  coal  up  a  long  flight  of  stairs  and  do  her  wash- 
ing and  ironing  almost  from  the  time  she  left  the  hospital,  and  also 
because  the  uterus  is  still  larger  than  natural.  In  the  other  case,  in 
which  catgut  was  used,  although  the  fundus  is  held  forward  by  the 
shortened  round  ligaments,  the  cervix  still  comes  forward,  although 
not  to  the  same  extent  as  before.  I  am  led  to  believe  from  my  experi- 
ence with  these  cases  that  a  shortening  of  both  ligaments  would  often 
give  satisftictory  results  in  cases  of  retroversion,  and  in  cases  of  pro- 
lapse or  even  procidentia  would  be  efficacious  in  connection  with  the 
operation  upon  the  round  ligaments  and,  if  necessary,  the  perineum. 

As  to  the  dangers  of  this  procedure,  only  a  few  drops  of  blood  es- 
caped, and  no  reaction  followed.  If  the  point  of  the  needle  be  not 
allowed  to  get  far  from  the  finger  end,  there  is  not  much  danger  of 


THE    ALEXANDER-ADAMS    OPERATION.  527 

injuring  the  rectum  or  upper  intestines.  Before  the  needle  is  pulled 
through,  an  assistant  should  introduce  the  finger  into  t\\e  rectum  for 
the  purpose  of  making  sure  that  the  needle  has  not  punctured  it. 
Septic  matter  might  also  be  carried  to  the  peritoneum  on  the  point  of 
the  needle  and  would  constitute  a  danger  in  case  antiseptic  precautions 
were  not  taken.  Possible  dangers  might  arise  from  breaking  the  needle, 
or  losing  track  of  the  point  and  puncturing  the  intestines  or  blood- 
vessels, or  from  carelessly  operating  upon  a  ligament  surrounded  by 
inflammation  or  induration. 

The  operation  could  undoubtedly  be  more  easily  done  by  making 
an  opening  into  the  cul-de-sac  large  enough  to  admit  one  finger  as  a 
guide.  The  point  of  the  needle  could  then  be  made  to  enter  the  cul- 
de-sac  through  the  cervical  attachment  of  the  sacrouterine  ligament 
and  to  enter  the  ligament  again  at  any  desirable  distance  back  of 
this,  and  thus  gather  up  a  fold  ;  and  after  being  drawn  through  it 
could  be  either  so  tied,  or  reintroduced  into  the  ligament  from  the 
peritoneal  side  near  the  cervix  and  be  brought  out  into  the  vagina  near 
its  point  of  entrance,  and  then  tied. 

This  is  perfectly  justifiable  when  the  cul-de-sac  is  already  opened 
for  the  removal  per  vaginam  of  an  ovary  lying  under  the  retroverted 
corpus ;  and  perhaps  by  means  of  a  special  opening  in  extreme  cases. 
The  abdominal  cavity  would  be  almost  entirely  shut  off  by  the  over- 
lying uterus.  The  stitches  could  both  be  passed  before  lifting  the 
'fundus,  and  then  tightened  one  immediately  after  the  other.  The  cul- 
de-sac  could  then  be  sponged  or  washed  out  and  closed  or,  if  any  ooz- 
ing were  noticed,  drained. 

I  have  performed  the  oj)eration  upon  the  cadaver  by  way  of  the  ab- 
dominal cavity  with  the  result  of  producing  anteversion  of  any  degree 
desirable.  It  could  be  done  on  the  living  subject  through  a  low  incision 
that  would  admit  one  hand  and  two  fingers  of  the  other,  and  might 
be  justifiable  in  cases  in  which  the  abdomen  was  already  opened  for 
other  purposes,  such  as  removal  of  the  appendages,  etc. 

Shortening  the  Round  Ligaments,  or  the  Alexander-Adams  Operation. 

The  Alexander-Adams  operation,  or  shortening  the  round  ligaments 
for  the  relief  of  certain  cases  of  retroversion,  is  based  upon  true  scien- 
tific principles,  for  it  restores  the  action  of  the  relaxed  round  ligaments 
in  drawing  the  fundus  uteri  forward,  and  bringing  the  abdominal 
pressure  to  bear  upon  the  posterior  surface  of  the  uterus.  The  abdomi- 
nal pressure  then  relieves  the  ligaments  of  their  burden  except  for  oc- 
casional short  periods  of  time.  It  is,  however,  unscientific  to  depend 
entirely  upon  the  operation  when  the  sacrouterine  ligaments  are  greatly 
at  fault,  for  means  should  be  taken  to  restore  them  also  to  function. 
When  the  sacrouterine  ligaments  are  chiefly  at  fault  they  should,  if 


628  DISPLACEMENTS   OF    THE    UTEEUS. 

possible,  be  shortened  first,  and  if  the  round  ligaments  cannot  then  be 
made  to  renew  their  function  they  may  be  shortened  afterward. 

Shortening  the  round  ligaments  was  suggested  by  Alquie*  of  Mont- 
pellier,  but  was  not  successfully  performed  on  the  living  subject  until 
December  14,  1881,  by  W.  Alexander  of  Liverpool.  Jas.  A.  Adams  of 
Glasgow,  without  a  knowledge  of  Alexander's  operations  performed  it 
in  Glasgow  in  1882.  It  has  now  been  performed  over  two  hundred 
and  fifty  times. 

Indications. 

The  indications  for  the  operation  are  a  persistence  of  retroversion 
(or  retroflexion)  with  distressing  symptoms  after  a  failure  of  other 
means.  In  case  of  prolapse  it  is  occasionally  indicated,  as  a  secondary 
to  other  operations  when  the  round  ligaments  allow  the  fundus  to  fall 
back  toward  the  sacrum. 

Con  train  dications. 

Among  the  contraindications  are  the  following :  all  conditions  that 
prevent  the  placing  of  the  uterus  in  a  position  of  anteversion  without 
discomfort  to  the  patient;  adhesion  of  thebroad  ligament  or  Fallopian 
tubes  to  the  back  part  of  the  pelvis  ;  acute  and  subacute  pelvic  inflam- 
mation, a  tense  state  of  the  ro,und  ligaments  while  the  uterus  is  retro- 
verted,  and  an  enlarged  ovary  and  tube  that  are  not  drawn  up  by  the 
replaced  uterus. 

The  Operation. 

The  operation  consists  in  cutting  down  upon  the  terminal  ends  of 
the  round  ligament  at  the  external  inguinal  ring,  drawing  them  out 
until  they  are  felt  to  move  the  previously  replaced  uterus,  cutting  off 
their  redundancy  and  stitching  their  ends  into  the  wound. 

An  incision  from  one  and  a  half  to  three  inches  is  made  from  the 
pubic  spine  along  the  upper  edge  of  Poupart's  ligament.  After  cut- 
ting through  the  skin  and  a  layer  of  subcutaneous  fat,  the  deep  layer 
of  the  superficial  fascia  is  encountered.  In  fleshy  people  another 
layer  of  fat  is  found  under  this  about  half  as  thick  as  the  first.  In 
slender  women  this  deeper  layer  of  fat  is  often  very  insignificant,  so 
that  we  come  almost  directly  to  the  coarsely  striped  intercolumnar 
fascia  covering  the  ring.  We  may  know  the  ring  b}^  its  tendency  to 
bulge,  and  at  the  same  time  by  its  depressibility  on  pressure.  The 
depression  immediately  under  Poupart's  ligament  does  not  bulge,  has 
a  harder  bottom,  and  is  less  definite  in  shape. 

The  intercolumnar  fascia  should  be  incised  in  the  direction  of  the 
external  wound,  but  only  from  the  pubic  spine  to  the  external  edge 
of  the  ring. 

The  superficial  epigastric  and  external  piibic,  which  are  generally  cut,  seldom  re- 
quire a  ligature,  as  they  are  easily  controlled  by  the  Langenbeck  serre-fiue  (Fig.  157). 

*  Aran,  Traits  des  Maladies  des  Femmes.     1858. 


THE   ALEXANDER- ADAMS   OPERATION.  529 

For  the  purpose  of  operating  rapidly  without  the  fear  of  cutting  too 
deeply,  I  have  had  a  pair  of  scissors  made,  bent  on  the  side,  and  with 
an  extended  probe-point  on  the  under  blade.  When  a  fascia  is  cut 
down  upon,  or  cut  through,  this  jDoint  is  slipped  either  over  or  under 
it,  and  the  incision  extended  by  one  cut  as  far  as  desirable. 

In  fleshy  women  a  ball  of  fat,  somewhat  smoother  and  more  delicate 
in  appearance  than  that  we  have  encountered  before,  will  fill  the  field  ; 
in  slender  patients,  however,  the  round  ligament  will  be  found  lying 
in  full  view  near  the  external  pillar  and  spreading  out  toward  the 
pubic  spine.  It  is  pinkish-white  and  round,  and  frequently  has  the 
small  white  glistening  genital  branch  of  the  genito-crural  nerve  lying 


Fig.  266. 


Byford's  Probe-pointed  Scissors  for  Cutting  Fascia. 

upon  it.  When  the  field  is  filled  with  fat  the  ligament  usually  lies 
imbedded  in  it,  or  surmounted  by  it.  The  fat  should  therefore  be 
pulled  or  dissected  ofi"  and  the  ligament  be  sought  close  to  the  inferior 
edge  of  the  ring.  If  the  mistake  is  made  to  poke  down  into  the  canal, 
the  ligament  will  not  be  easily  found,  for  it  there  resembles  the  ten- 
.dinous  bands  and  aponeurotic  edges  closely  and  descends  rapidly 
beneath  them. 

When  the  round,  pinkish,  slightly  mottled  ligament  cannot  be  dis- 
tinguished from  the  muscular  and  aponeurotic  edges,  there  are  two 
sensations  which  belong  to  the  ligament  when  grasped  by  the  forceps 
that  may  help  in  finding  it,  viz. :  the  ligament  usually  feels  elastic 
when  pulled,  and  it  bleeds  but  little  when  loosened  from  its  surround- 
ings. The  aponeurotic  edges  may  be  pulled  out  a  certain  distance 
and  then  may  resist  suddenly,  and  if  pulled  much  harder,  break, 
while  the  round  ligament  resists  pulling  in  a  more  gradual  or  elastic 
manner.  Everywhere  that  the  aponeurotic  or  muscular  edges  are 
separated  blood  oozes  from  the  torn  surface. 

When  the  ligament  has  been  seized  by  the  forceps  at  the  inguinal 
ring,  it  is  so  intimately  attached  to  the  external  (inferior)  pillar  by  its 
fibres,  and  their  connective  tissue  or  fascial  covering,  that  it  will  be 
necessary  to  thrust  the  scissors-point  through  this  thinner  membranous 
portion,  connecting  the  ligament  with  the  edge  of  the  ring,  in  order  to 
hook  up  the  ring.  I  have  had  a  hook  constructed  that  is  widened 
and  flattened  in  the  curve  so  as  to  present  a  surface  of  one-eighth  of 
an  inch  to  the  ligament,  and  is  sufficiently  sharp  on  the  point  to 
penetrate  the  connective  tissue  under  and  about  the  ligament  without 
any  previous  puncture.     With  this  the  ligament  may  be  lifted  and 

34 


530  DISPLACEMENTS    OE   THE    UTERUS. 

put  upon  the  stretch,  while  with  a  fine  pair  of  scissors  curved  on  the 
flat,  we  clip  off  the  loose  fibres  that  connect  the  sheath  with  the  ingui- 
nal canal.  We  should  then  use  the  fingers  in  preference  to  the  hook 
in  pulling  upon  it.  If,  after  loosening  the  ligament  as  far  as  we  can 
see,  it  does  not  "  peel  out "  or  "  run,"  we  may  slit  up  the  canal  for  a 
short  distance  in  order  to  continue  the  separation.  If  the  ligament 
still  cannot  be  made  to  run  by  moderate  traction,  we  must  dissect  off 
its  entire  sheath  for  a  short  distance  all  around  and  then  draw  it  out. 
After  one  ligament  is  thus  separated  so  as  to  run,  it  should  be  dropped 
and  a  clean  sponge  laid  in  the  wound  until  the  other  ligament  is 

Fig.  267. 


^^^^^fe^^^^^ 


By  ford's  Broad  Hook. 

loosened.  It  is  better,  as  Alexander  has  suggested,*  to  stand  on  the 
side  opposite  to  the  incision  that  is  being  made  in  order  to  be  able  to 
look  deeper  into  the  canal. 

The  ligaments  being  loosened,  the  next  step  is  to  replace  the  uterus 
by  the  finger,  a  sound,  or  an  intrauterine  stem,  and  have  it  so  held  by 
an  assistant.  The  ligaments  are  then  drawn  out  until  they  are  felt  to 
move  the  uterus.  Not  infrequently  the  inverted  sheath  is  drawn  into 
view  and  must  be  peeled  back  out  of  the  way. 

The  next  step  is  to  stitch  the  ligament  to  the  ring.  This  may  be 
done  by  three  medium-sized  juniper  catgut  sutures  passed  from  the 
external  or  internal  side  of  the  ring  through  the  round  ligament  to 
the  opposite  side.  When  tied  loosely  so  as  not  to  constrict  the  liga- 
ment, they  close  the  upper  external  end  of  the  ring  and  incised  edge 
of  the  canal,  and  leave  room  for  a  small  drainage-tube  underneath. 
I  then  cut  off  the  superfluous  portion  of  the  ligament  and  attach  the 
divided  ends  by  a  catgut  suture.  In  my  last  two  cases  I  have  used 
silkworm  catgut. 

Alexander t  "stitches  each  (ligament)  to  both  pillars  of  tlie  ring  by  two  sutures  on 
each  side,"  cuts  off  the  ''chafed  ends"  and  stitches  the  remainder  "  into  the  wound  by 
means  of  the  sutures  that  close  the  external  incision." 

I  then  introduce  a  small  drainage-tube  into  the  canal  under  the 
ligament,  dust  a  little  iodoform  into  the  external  wound  and  sew  it  up 
with  silk.  One  of  the  external  sutures  is  passed  deep  enough  to  in- 
clude the  ligament.  A  one  per  cent,  solution  of  carbolic  acid  is  then 
injected  into  the  tube  to  more  completely  cleanse  the  deeper  wound, 
and  an  antiseptic  dressing  of  iodoform  gauze,  cotton  smeared  with  a 

*  British  Gyn.  Journal,  Part  III.,  November,  1885. 
f   Op.  cit. 


THE   ALEXAJSTDEE-ADAMS    OPERATION.  531 

ten  per  cent,  solution  of  carbolic  acid  in  glycerine,  or  the  equivalent, 
should  be  placed  over  the  wound.  A  Hodge  or  Albert  Smith  pessary 
which  has  been  previously  fitted  should  be  introduced,  and,  if  the 
uterus  be  much  flexed,  a  stem  pessary. 

The  drainage-tube  should  be  taken  out  as  soon  as  the  discharge  of 
bloody  serum  has  ceased,  viz. :  in  twentj^-four  to  forty  hours.  Its 
track  should,  however,  be  first  washed  out  by  another  injection  of  the 
carbolic  acid  solution.  If  the  dressings  become  saturated  they  may 
be  changed  before  that  time,  and  once  in  twenty-four  hours  after. 
Union  by  first  intention  may  then  be  expected  in  patients  that  are  not 
too  fat  or  too  poorly  nourished.  After  all  discharge  has  ceased  I  use 
a  dry  iodoform  dressing. 

The  stitches  should  be  removed  in  five  or  six  days  and  a  few  adhe- 
sive straps  applied. 

After-  Treatment. 

The  patient  should  be  kept  in  bed  between  two  and  three  weeks, 
and  should  not  walk  until  after  three  weeks  nor  perform  any  hard 
work  until  after  six  or  eight  weeks  have  elapsed.  The  stem  pessary 
should  be  worn  from  two  to  three  months,  the  vaginal  pessary  from 
three  to  twelve  months,  or  until  the  sacro-uterine  ligaments  become 
contracted  so  as  to  hold  the  cervix  back  in  place. 

Results  of  the  Operation — Cases. 
'My  own  experience  extends  to  ten   cases,  seven   performed  by 
myself  and  one  by  my  assistant.  Dr.  Carrie  N.  White,  at  the  clinic  in 
the  Woman's  Hospital. 

In  the  first  case,  Miss  B w,  aged  24,  tliere  was  a  sliglit  irreducible  retroflexion. 

Pessaries  could  only  be  tolerated  for  a  short  time  before  causing  distress.  Five  years 
treatment,  the  last  two  by  myself,  had  failed  to  put  her  in  a  condition  to  do  the  house- 
work for  herself,  mother  and  brother.  Dysmenorrhoea,  attacks  of  uterine  colic  and 
vesical  tenesmus  from  once  to  twice  a  month  had  confined  her  to  bed  for  a  day  or  two 
each  time,  previous  to  the  operation.  The  pessary  was  removed  six  weeks  after  the 
operation.  Glycerin  tampons  worn  about  half  of  the  time  for  a  month  longer,  and  then 
about  two  days  out  of  the  week.  At  first  the  cervix  hung  low,  so  as  to  reach  almost  to 
the  coccyx,  but  the  fundus  remained  in  front  of  the  pelvic  axis.  The  first  two  or  three 
menstrual  periods  were  painful,  but  since  then  she  has  steadily  improved.  Dysmen- 
orrhcea,  uterine  colic  and  bladder  symptoms  are  all  gone.  The  sacro-uterine  ligaments 
have  contracted  somewhat,  so  that  both  the  cervix  and  fundus  are  now  (over  a  year 
after  the  operation)  normal  in  position,  although  a  very  slight  retroflexion  persists. 
Is  now  able  to  do  her  work.     (Woman's  Hospital.) 

In  the  second  case,  Mrs.  K p,  the  results  were  not  so  satisfactory.  The  opera- 
tion was  performed  for  the  relief  of  severe  dysmenorrhoea  and  backache  combined 
with  sterility  that  was  getting  worse  in  spite  of  treatment.  There  was  a  gonorrhceal 
salpingitis  of  right  side  with  some  contraction  in  upper  part  of  the  broad  ligament. 
No  pessary  could  be  found  that  would  keep  the  uterus  in  place  during  the  performance 
of  her  household  duties.  She  was  unwilling  to  submit  to  a  salpingotomy.  The  liga- 
ments were  easily  drawn  out,  but  the  operation  was  followed  by  an  acute  attack  of  local 


532  DISPLACEMENTS   OF   THE    UTERUS. 

peritonitis  or  peri-salpingitis,  probably  due  to  the  breaking  np  of  adhesions.  Highest 
temperature  101°  F.,  on  fourth  day.  Walked  across  floor  twenty-three  days  after  the 
operation  without  disconafort.  Menstruated  seven  weeks  after  operation  with  less  pain 
than  usual.  Pessary  removed  in  six  weeks.  About  a  week  after,  the  uterus  became 
retroverted  while  she  was  leaning  over  the  stove,  and  another  attack  of  peri-salpingitis, 
with  excessive  nausea,  followed.  Highest  temperature,  101 1°  F.  Saw  her  next  day 
and  reintroduced  a  pessary.  Fallopian  tube  felt  in  right  sacral  pouch,  enlarged. 
Temperature  normal  on  seventh  day.  Had  a  slighter  attack  at  the  beginning  of  next 
two  menstrual  periods.  Substituted  a  Thomas  for  the  Albert  Smith  pessary.  She  has 
had  no  acute  attack  since,  and  is  now,  eleven  months  after  the  operation,  free  from 
her  old  backache  (which  has  not  troubled  her  since  the  operation),  and  menstruates 
without  pain,  and  is  satisfied  if  she  can  remain  as  well  as  now.  Slie  still  wears  the 
Thomas  pessary.     (Woman's  Hospital.) 

In  the  third  case,  Mrs.  D ,  the  subinvoLited  uterus  seemed  to  be  held  in  retro- 
version by  the  weight  of  the  enlarged  right  ovary  and  tube  lying  in  the  cul-de-sac  of 
Douglas.  The  cervix  appeared  at  the  vaginal  entrance  whenever  the  pessary  was  left 
out  for  any  length  of  time  The  operation  was  followed  by  no  disagreeable  symptoms. 
The  pessary  was  removed  after  three  months  and  left  out  for  a  few  days,  but  was  rein- 
troduced because  the  cervix  came  forward  and  the  enlarged  uterus  literally  hung  upon 
the  round  ligaments.  The  ovary  and  tube  could  not  be  reached  by  the  vaginal  finger. 
The  pessary  was  removed  after  seven  months,  and  the  uterus  found  slightly  retroverted 
the  next  day.  When  replaced  it  remained  temporarily  in  a  normal  position,  showing 
that  the  ligaments,  although  unable  to  hold  the  heavy  uterus  and  ovaries  up  during 
active  exercise,  were  not  relaxed  as  before  the  operation.  The  ovary  followed  the 
uterus.     The  pessary  was  replaced.     (Private  family.) 

The  fourth  case,  Mrs.  T ,  is  one  in  which  a  cicatricial  shortening  of  left  broad 

ligament  (due  to  a  lacerated  cervix  with  subsequent  inflammation)  was  all  that  pre- 
vented a  procidentia.  The  left  ovary  and  tube  were  adherent  to  the  broad  ligament, 
tlie  right  ovary  slightly  enlarged  and  lying  in  the  rectouterine  peritoneal  pouch. 
Moderate  right  diagonal  laceration  of  the  perineum  and  pelvic  floor,  relaxing  the  pel- 
vic outlet.  Subinvolution.  She  had  been  treated  by  two  pi'ominent  gynecologists,  but 
obtained  no  relief.  None  of  us  could  fit  a  pessary  that  could  be  tolerated.  It  had 
been  proposed  to  remove  the  appendages.  In  operating  I  found  the  left  ligament 
enlarged  to  about  twice  the  normal  diameter  by  the  increase  of  connective  tissue,  and 
the  right  one  much  smaller  than  usual.  A  pessary  was  from  that  time  worn  without 
discomfort,  except  from  its  tendency  to  protrude.  Four  weeks  after  the  operation 
unilateral  perineorrhaphy  was  performed.  After  this  the  uterus  hung  upon  the  broad 
ligament,  with  the  cervix  just  behind  the  newly-formed  recto-vaginal  promontory, 
and  before  it  was  considered  safe  for  her  to  wear  a  pessary  the  right  ligament  had 
relaxed  so  as  to  allow  the  right  horn  to  swing  laack  a  little.  The  left  side  lield.  She 
now  wears  a  small  Hodge  pessary  (seven  months  afterward)  with  comfort,  and  feels 
belter  than  for  years.  The  old  ovarian  pain,  for  which  the  appendages  were  to  be 
removed,  is  gone.     (Woman's  Hospital.) 

The  fifth  case,  Mrs.  H — -e,  was  one  of  subinvolution  and  retroversion  with  con- 
traction in  the  left  broad  ligament  and  relaxation  of  all  the  others.  There  was  also  a 
rectocele  due  to  an  uncicatrized  transverse  perineal  laceration.  A  Scott  pessary  was 
the  only  one  that  could  be  used  with  any  benefit.  I  relieved  the  rectocele  by  a  plastic 
operation,  and  was  then  able  for  awhile  to  hold  the  uterus  in  position  with  a  Hodge 
pessary.  But  in  a  short  time  the  perineum  began  to  relax  and  the  uterus  turned 
backward  over  the  pessary,  no  matter  how  much  I  increased  tiie  size.  I  preceded  the 
Alexander  operation  by  a  stitch  in  the  right  sacrouterine  ligament,  taken  with  silk- 
worm gut.     Tlie  cervix  was  held  back  by  vaginal  tampons  for  the  first  ten  days  and 


THE   ALEXANDER-ADAMS   OPERATION.  533 

afterwards  by  a  much  smaller  sized  Hodge  pessary  than  those  that  had  before  failed 
to  do  so.  All  symptoms  of  ill  health  rapidly  subsided,  and  she  was  doing  her  washing 
and  housework  in  two  months  after  the  operation.  She  feels  entirely  well.  The 
cervix  remains  higher  in  the  pelvis  than  normal  when  the  pessary  is  removed.  On 
account  of  the  enlargement  of  the  uterus  and  the  amount  of  hard  work  she  is  obliged 
to  do  I  have  not  yet  thought  it  safe  to  remove  the  pessary.  It  is  six  months  since  the 
operation  was  performed.     (Woman's  Hospital.) 

In  the  sixth  case,  Mrs.  S ,  performed  over  five  months  ago,  the  retroversion 

resisted  the  pessary  treatment  for  a  year,  and  was  accompanied  by  backache  and  in- 
ability to  perform  her  household  duties  with  comfort.  She  was  anxious  for  relief.  I 
was  unable  to  make  the  ligaments  run  satisfactorily,  but  removed  three-quarters  of  an 
inch  from  each,  and  inserted  the  stitches  so  as  to  draw  the  ligaments  a  little  farther 
out.  The  inguinal  ring  was  literally  filled  with  veins  and  small  arteries.  Notwith- 
standing the  failure  to  satisfactorily  shorten  the  ligaments,  the  uterus  was  more  com- 
pletely anteverted  by  the  pessary  than  before,  and  now  remains  in  a  state  of  ante- 
version  when  the  pessary  is  removed.  The  result  could  not  have  been  better  had  I 
removed  three  inches  of  ligament.     The  pessary  is  still  worn.     (Woman's  Hospital.) 

In  the  seventh  case  there  was  a  contraction  of  the  left  broad  ligament,  and  a  small- 
ness  of  the  vagina  (although  she  had  borne  an  illegitimate  child  a  number  of  years 
before)  that  made  all  pessaries  either  useless  or  intolerable.  The  ligaments  were  only 
about  half  the  normal  thickness,  and  were  made  to  run  with  difBculty.  She  still  wears 
the  pessary.  Improvement  was  gradual.  Two  months  after  the  operation  she  was  not 
able  to  work  as  well  as  before.  Four  months  after  she  could  work  better.  (Woman's 
Hospital.) 

Case  eight  was  one  of  extreme  retroflexion,  in  which  pessaries  were  useless  ana 
could  not  be  tolerated.  No  trouble  was  experienced  in  the  operation,  except  the  ad- 
justment of  the  pessaries.  A  hard  rubber  intrauterine  stem  to  control  the  tendency  of 
the  uterus  to  double  up  or  "  recoil,"  and  a  small,  well-curved  Hodge  pessary  were 
finally  made  to  hold  the  cervix  and  uterus  in  their  proper  relations  with  the  fundus. 
The  stem  slipped  out  two  or  three  times  during  the  first  three  weeks,  but  soon  lost 
that  tendency.  Two  months  after  the  operation  the  pessaries  were  removed,  but  as 
there  was  still  a  tendency  to  flexion  and  a  relaxed  condition  of  the  sacrouterine  liga- 
ments the  Hodge  was  again  introduced.     (Woman's  Hospital,  Dr.  White.) 

Case  nine  was  one  of  extreme  retroflexion  of  a  flabby  uterus.  An  intrauterine  stem 
was  used.  She  was  doing  her  housework  in  two  months  completely  relieved  of  all 
symptoms.     (St.  Luke's  Hospital.) 

Case  ten  is  too  recent  to  be  reported.     (Woman's  Hospital.) 

A  study  of  these  cases  has  led  me  to  expect  less  of  the  operation, 
but  (expecting  less)  to  regard  it  as  one  of  the  most  valuable  of  the 
recent  additions  to  minor  gynecology.  It  is  applicable  scientifically 
to  only  a  small  percentage  of  cases  of  retroversion  and  retroflexion, 
and  then  is  often  only  an  aid  to  other  measures, or  one  among  others; 
but  as  such  it  gives  most  satisfactory  results.  When  employed  as  a 
sole  remedy  it  frequently  fails,  but  when  employed  as  a  step  toward 
the  cure,  preceded  and  followed  by  other  appropriate  and  no  less 
necessary  treatment,  it  does  not  disappoint.  Perhaps  its  most  strik- 
ing result  is  the  comfort  and  benefit  with  which  a  pessary  (including 
the  intrauterine  stem)  can  be  subsequently  worn.  If  the  operation 
did  nothing  else  it  would  still  have  a  just  claim  to  recognition  as  a 
scientific  procedure.     In  view  of  the  recurrence  of  the  displacement 


534 


DISPJ.ACEMEXTS    OF    THE    UTERUS. 


in  ray  second  case  I  consider  it  safer  to  leave  the  pessary  in  the  vagina 
from  six  to  eight  months.  This  prolonged  use  of  the  pessary  is  par- 
ticularly indicated  when  a  contraction  in  or  about  a  broad  ligament 
prevents  the  uterus  lying  comfortably  in  a  position  of  moderate  ante- 
version.  Theoretically,  such  a  contraction  would  contraindicate  the 
operation,  but  practically  there  is  often  nothing  better  to  be  done;  and 
there  is  a  better  prospect  of  a  final  adjustment  of  the  tissues  than 

without  it. 

Dangers  and  Difficulties. 

"When  properly  performed  there  is  almost  no  danger  connected  with 
Alexander's  operation ;  when  carelessly  or  ignorantly  performed 
hemorrhage,  peritonitis,  interfascial  suppuration  and  pyeemia  are 
liable  to  result  as  from  any  operation.  Pyaemia  from  suppuration 
occurring  in  the  deeper  portions  of  the  wound  has  been  the  cause  of 
most  of  the  deaths.  A  drainage  tube  to  the  bottom  of  the  wound 
and  removed  in  twenty-four  hours  is  no  hindrance  to  union  by  first 
intention,  and  avoids  the  retention  of  the  sero-sanguineous  oozing 
that  alwaj's  follows  during  the  first  few  hours  after  the  operations. 

The  difiiculties  are  numerous  to  the  beginner,  but  rapidly  vanish 
by  a  minute  study  of  the  various  steps.  It  is  better  to  see  it  per- 
formed before  attempting  it,  or  else  to  study  it  upon  the  cadaver. 


Raising  of  the  Perineum  or  Pelvic  Floor. 
As  the  perineum  and  pelvic  floor  play  an  important  part  in  sustain- 
ing the  pelvic  viscera,  the  uterus  cannot  be  expected  to  remain  in 


Fig.  268. 


Curves  of  Posterior  Vaginal  and  Rectal  Walls  after  a  poorly  performed  Perineorrhaphy, 
lines  show  the  normal  curves,  the  heavy  Lines  the  faulty  ones. 


Dotted 


proper  place  when  they  are  relaxed  or  lacerated.  Hence  any  course 
of  treatment  looking  to  a  permanent  cure  of  retroversion  should  not 
leave  these  parts  out  of  consideration.  But  not  only  must  the  vaginal 
outlet  be  restored,  but  the  muscles  and  fasciae  must  be  drawn  together 


OP±.KATI0N  FOR  HOLDING  OR  FIXING  THE  CERVIX  BACKWARD.       535 

SO  as  to  form  a  firm  and  resistant  as  well  as  a  high  recto-vaginal  pro- 
montory against  which  the  cervix  will  find  rest  and  the  uterine  liga- 
ments be  relieved  from  tension  during  the  action  of  strong  abdominal 
pressure.  The  fibres  and  fascia  of  the  levator  ani  under  the  rectum 
must  also  be  raised  or  pulled  forward  to  their  normal  place,  and 
the  lower  curve  of  the  posterior  rectal  wall  (see  Figs.  31  and  54)  be 
restored. 

The  shape  of  the  denudation  is  determined  by  the  location  and 
extent  of  the  relaxation  fsee  chapter  on  perineorrhaphy).  The  vaginal 
walls,  the  pelvic  floor,  the  perineum,  separately  or  simultaneously  as 
a  whole,  or  in  a  particular  region,  may  be  at  fault,  and  require  the 
operation  to  be  chiefly  within  the  vagina  or  entirely  about  the  vulvo- 
vaginal entrance. 

Operations  of  Expedience. 

These  operations  fix  the  fundus  forward  or  the  cervix  backward, 
and  although  seldom  strictly  scientific  may  be  useful  as  substituting 
a  lesser  evil  for  a  greater  one. 

Abdominal  Section  for  Fixing  the  Fundus  Fonuard. 

Abdominal  section  for  the  cure  of  retroversion  or  retroflexion 
usually  has  for  its  object  the  stitching  of  the  upper  end  of  the  uterus, 
the  cornua,  the  round  ligaments  or  their  appendages  to  the  abdominal 
-wall  above  the  pubes.  Koeberle  was  the  first  to  perform  it  while 
operating  for  removal  of  the  ovaries.  Since  then  it  has  been  done  by 
Mueller,  Lawson  Tait,  Skene  Keith,  Heywood  Smith,  William  H. 
Byford,  Hennig,  Czerny,  Bardenhauer,  H.  A.  Kelly,  Polk  and  others. 

It  is  as  a  ride  not  justifiable  to  open  the  abdominal  cavity  primarily 
for  the  cure  of  retroversion,  yet,  as  Olshausen,  Kelly,  Polk  and  Hey- 
wood Smith  have  maintained,  it  does  occasionally  become  necessary 
in  extreme  cases,  after  other  treatment  has  failed.  The  chief  criticism 
to  be  made  is  that  a  fixed  anteversion  or  anteflexion  is  substituted, 
and  that  those  who  have  opened  the  abdominal  cavity  particularly  for 
this  purpose  have  not  always  tried  every  other  means. 

Olshausen*  and  H.  A.  Kellyf  suspend  both  uterine  horns,  utilizing 
the  broad  ligament,  round  ligament  and  the  Fallopian  tube,  if  their 
function  is  no  longer  needed,  and  employ  from  two  to  three  sutures 
on  either  side.  William  H.  Byford  depends  mainly  upon  the  round 
ligaments. 

Operation  for  Holding  or  Fixing  the  Cervix  Bachvard. 

It  has  been  attempted  to  cause  cicatricial  contraction  of  the  pos- 
terior vaginal  wall  by  cautery  (Amussat),  to  obtain  adhesive  inflam- 
mation between  the  cervix  and  posterior  fornix,  and  to  unite  these 

*  Centralb.  f.  Gyn.,  No.  43,  1886.  f  Medical  News,  December  4,  1886. 


536  DISPLACEMENTS   OF   THE   UTERUS. 

tissues  by  denuding  them  and  stitching  them  together  (Lowenthal, 
Hunter,  0.  E.  Herrick).  As  a  secondary  procedure  in  rare  cases  the 
last  mentioned  one  may  be  worth  remembering.  Stitching  the  anterior 
lip  of  the  cervix  and  the  upper  end  of  the  anterior  vaginal  wall  to  the 
posterior  vaginal  wall,  while  the  uterus  is  held  in  moderate  antever- 
sion,  may  also  be  of  occasional  use  in  connection  with  it.  The  vagina 
must  of  course  not  be  occluded.  The  Sims-Emmet  triangular  opera- 
tion upon  the  anterior  vaginal  wall  (Fig.  233)  is  occasionally  appli- 
cable to  retroversions. 

Treatment  of  Uterine  Flexions. 

What  has  been  said  about  the  treatment  of  uterine  versions  applies 
also  to  flexions,  and  will  be  sufficient  if  the  flexion  be  moderate. 
When  it  is  congenital  or  extreme  in  degree  and  accompanied  by  dys- 
menorrhoea  {q.v.),  other  treatment  may  be  indicated. 

In  the  congenital  variety  means  for  normally  developing  the  mus- 
cular and  sexual  system  are  of  especial  importance,  such  as  massage, 
walking,  out-door  games,  gymnastics,  association  with  the  opposite 
sex,  marriage,  pregnancy,  etc.  Dilatation  by  Peaslee's  or  Hanks' 
dilators,  commencing  with  the  smallest,  relieves  the  dysmenorrhoea, 
stimulates  the  uterus  and  often  cures  the  sterility.  Compressed  slip- 
pery elm  tents  (Fig.  96)  curved  to  suit  the  shape  of  the  uterine  cavity 
are  often  preferable  because  of  their  curve,  and  because  they  can  be  left 
in  place  from  one  to  several  hours  and  thus  act  as  a  powerful  stimu- 
lant. If  the  uterine  substance  be  hard,  violence  must  not  be  done  to 
it  by  forcing  a  hard  straight  dilator  into  it.  If  these  means  be  in- 
efficient and  the  uterus  remain  small,  flexed  or  flabby,  without  any 
signs  of  inflammation,  the  uterine  stem  may  be  tried,  partly  to  splint 
the  uterus  or  hold  it  straight,  but  i3rincij)ally  to  act  as  a  powerful 
stimulant. 

Fig.  269. 


Jackson's  lutra-Uterine  Stem. 

In  case  of  acquired  flexion  or  that  coming  on  after  puberty,  or  after 
childbirth  or  abortion,  a  stem  may  be  necessary  to  hold  the  uterus 
straight  that  the  pessary  in  the  vagina  may  become  effective.  In  the 
eighth  and  ninth  cases  of  the  Alexander  operation  already  reported  in 
this  chapter,  its  use  was  well  illustrated  as  necessary  to  render  both 
the  shortening  of  the  ligaments  and  the  Hodge  pessary  effective.  The 
stem  should  not  as  a  rule  be  attached  to  the  other  pessary. 

If  the  uterus  be  hardened  the  stem  must  have  a  similar  although  a 


TREATMENT    OF    UTERINE    FLEXIONS.  537 

slighter  curve  than  the  uterine  cavity.  If  the  uterus  be  flabby  it  may 
be  straightened  by  the  probe  and  a  straight  stem  slipped  in  beside  the 
probe  as  far  as  the  constricted  point,  and  pushed  farther  in  as  the 
probe  is  withdrawn.  It  is  easier  to  introduce  it  with  a  Sims's  speculum, 
or  in  the  dorsal  position  without  a  speculum,  so  that  it  can  be  held  in 
place  by  the  finger  until  the  vagina  closes  upon  it.  The  stem  should 
be  of  hard  rubber  or  whalebone  from  an  eighth  to  a  sixteenth  of  an  inch 
in  diameter,  and  a  quarter  of  an  inch  shorter  than  the  uterine  cavity. 
It  should  have  a  button-shaped  or  globular  piece  on  the  vaginal  end 
to  protect  the  vagina  and  keep  it  from  passing  too  far  into  the  uterus. 
Jackson's  soft  rubber  stem  is  useful  in  developing  the  uterus,  prevent- 
ing stenosis  and  favoring  the  occurrence  of  pregnancy,  and  is  less  apt 
to  do  harm  in  inexperienced  hands.  It  of  course  has  less  power  than 
the  hard  ones  to  immediately  straighten  the  uterus,  and  is  of  less 
assistance  to  a  retroversion  pessary  in  holding  the  organ  in  its  natural 
place  and  position. 

Anteversion  and  anteflexion  pessaries  have  been  variously  modified 
for  the  treatment  of  flexions.  Thomas  has  thickened  the  posterior  end 
of  the  Albert  Smith  pessary  and  given  the  arms  a  sharper  curve  so  as 

Fig.  270. 


Thomas's  Bui'u  Kecroflexion  Pessary — Elastic. 

to  form  a  high  broad  rest  for  the  retroflexed  body  of  the  uterus.  Fig. 
270  represents  the  same,  made  of  spring  wire  and  covered  with  soft 
rubber.  The  retroversion  pessaries  acting  both  in  front  and  behind 
the  cervix  (page  523)  are  also  useful  in  retroflexions  as  they  get  a 
firmer  hold  on  the  cervix  and  vaginal  fornices.  Anteversion  pessaries 
may  be  modified  anteflexion  so  as  to  press  farther  in  front  of  the  cervix 
and  thus  by  lifting  the  bladder  i:)roduce  an  effect  upon  the  upper  por- 
tion of  the  uterus. 

In  applying  tampons  for  flexions  we  should  avoid  making  use  of 
ordinary  leverage  force  applied  to  the  end  of  the  cervix,  as  that  would 
only  increase  the  flexion.  In  retroflexion  we  apply  one  or  two  tam- 
pons behind  the  cervix,  and  push  them  high  uj)  along  its  posterior 
surface  so  as  to  fill  as  near  as  possible  the  angle  formed  by  the  flexion. 
We  then  push  the  cervix  back  against  the  tampons  (which  in  turn 
lift  the  fundus),  and  fill  the  vagina  in  front  of  the  cervix,  as  recom- 


538  DISPLACEMENTS    OF   THE   UTERUS. 

mended  by  Thomas.  If  it  be  desirable  to  lift  the  whole  organ  we  may 
also  put  a  small  tampon  in  each  lateral  fornix  beside  the  cervix  and  a 
soft  flattened  one  under  the  end  of  it.  For  anteflexions  the  tamj)ons 
are  placed  as  for  anteversion,  except  the  lower  or  anterior  ones  are  made 
a  little  larger  in  order  to  press  up  the  tissues  toward  the  part  of  the 
uterus  above  the  curve,  and  also  to  fill  the  angle. 


CHAPTEE    XXXII. 

DISPLACEMENTS  OF  THE  UTERUS   {Continued). 

Retroversion  and  Retroflexion  of  the  Uterus  during  Pregnancy. 

The  uterus  is  sometimes  found  retroverted  or  retroflexed  during 
pregnancy.  When  small  during  the  first  few  weeks  of  pregnancy,  its 
existence  is  not  observed  because  it  produces  no  inconvenience,  and  it 
is  not  until  it  grows  large  enough  to  partly  or  completely  fill  up  the 
pelvis  that  anything  is  known  of  it  unless  discovered  by  accident.  If 
it  is  examined  at  such  time,  the  os  uteri  will  be  found  against  the 
symphysis  pubis,  sometimes  but  little  above  the  arch,  but  occasionally 
as  high  as  the  top  of  that  junction.  If  the  uterus  is  retroverted  fully, 
the  mouth  looks  upward  and  forward ;  if  retroflexion  exists,  the  os  is 
still  at  the  symphysis,  but  its  opening  is  directed  downward  and  for- 
ward. In  this  last  case  the  cervix  is  bent  upon  itself  at  a  sharp  angle, 
the  lower  extremity  as  before  remarked  looking  downward  and  for- 
ward, and  the  uterine  extremity  turned  backward  and  downward.  So 
that  the  difference  in  these  two  conditions  consists  in  the  bent  state  of 
the  cervix,  and  not  in  the  position  of  the  uterus.  The  body  of  this 
organ  has  its  axis  reversed  almost  completely,  the  fundus  extremity 
running  through  the  lower  bone  of  the  sacrum,  while  the  upper  ex- 
tremity of  the  axial  line  passes  out  of  the  abdomen  above  the  sym- 
physis. The  body  lies  in  the  hollow  of  the  sacrum  included  in  the 
peritoneal  cul-de-sac  between  the  vagina  and  the  rectum.  Both  these 
canals  are  compressed,  the  rectum  hard  against  the  sacrum  and  the 
vagina  up  against  the  pelvic  bone.  The  direction  of  the  vagina  is 
upward  and  forward  instead  of  backward,  its  usual  course.  The  finger 
cannot  be  made  to  sink  deep  into  the  vagina  except  behind  the  pubis ; 
in  introducing,  it  turns  upward  and  forward.  The  urethra  runs  up  in 
close  contact  with  the  symphysis  pubis,  and  is  narrowed  very  mate- 
rially by  extension  and  pressure,  so  that  it  very  imperfectly  performs 
the  function  of  a  viaduct  from  the  bladder. 

Causes. 

Although  pregnancy  usually  corrects  misplacements  of  the  uterus, 
such  is  not  always  the  case,  for  this  condition  is  sometimes  a  mere 
continuation  of  its  unimpregnated  position.  It  is  well  understood  by 
accoucheurs  also,  that  in  the  early  months  of  pregnancy  the  normal 
position  of  the  organ  is  depression,  and  that  prolapse  and  retrover- 
sion are  not  unusual  'effects  of  recent  impregnation.     Under  certain 


540  DISPLACEMENTS   OF   THE   UTERUS. 

circumstances  this  last  deviation  is  not  corrected  by  the  advance  of 
growth  in  the  organ.  Where  other  causes  co-operate,  a  distended 
bladder  may  aid  in  causing  the  uterus  to  assume  and  retain  this  posi- 
tion, as  may  also  loaded  intestines  pressing  upon  the  fundus  and 
anterior  face.  These  causes  and  perhaps  others  operate  to  bring  about 
a  gradual  displacement,  but  there  are  some  that  produce  the  condition 
suddenly.  It  should  be  remembered  that  it  is  only  at  a  certain  time 
that  these  sudden  causes  can  produce  the  effect,  and  that  is  after  the 
end  of  the  third  month  and  before  the  beginning  of  the  fifth  month. 
It  is  about  this  time  that  the  uterus  attains  a  bulk  sufficient  to  partly 
or  entirely  fill  up  the  pelvic  cavity.  If  when  it  has  attained  this  size, 
a  sudden  impulse  is  imparted  to  the  fundus  and  anterior  face  of  the 
organ,  the  fundus  may  be  crowded  so  low  into  the  hollow  of  the  sacrum 
as  to  reverse  the  axis.  In  this  state  the  forces  acting  in  favor  of  cor- 
rection are  feeble  and  may  fail  to  bring  it  about.  Strong  abdominal 
pressure  upon  the  intestines  and  bladder  under  tenesmus,  falls  upon 
the  feet  or  breech,  lifting  heavy  weights,  and  even  severe  sneezing  and 
coughing,  are  occasionally  causative.  In  the  cases  where  the  efficient 
causes  are  suddenly  applied,  the  symptoms  are  acute  and  established 
at  once.  In  the  other  cases  the  train  of  symptoms  gradually  make 
their  appearance. 

Symptoms. 

When  induced  suddenly  the  patient  is  seized  with  great  pain  in  the 
back,  with  a  sense  of  weight  upon  the  perineum,  constipation,  reten- 
tion of  urine,  tenesmus,  dragging  sensation  in  the  loins,  and  often, 
though  not  always,  sickness  of  stomach  and  vomiting.  If  gradually 
established,  the  pains,  constipation,  and  retention  of  urine  are  slowly 
established,  requiring  from  seven  to  twenty-one  days  or  more,  to  ren- 
der them  intolerable.  I  knew  a  case  caused  by  a  woman  riding  all 
day  in  railroad  cars  without  urinating. 

There  are  two  important  symptoms,  viz.,  retention  of  the  urine  and 
of  the  fseces ;  from  these  result  most  of  the  distress  complained  of. 
Great  distension  of  the  bladder  and  the  terrible  suffering  thereby  pro- 
duced, is  the  worst.  The  student  should  bear  in  mind  that  quite  fre- 
quently this  symptom  is  deceptive.  The  urine  is  constantly  dribbling 
from  the  meatus,  and  the  patient  thinks,  and  will  say,  she  passes 
plenty  of  urine.  The  fact  of  this  constant  slight  discharge  should 
cause  us  to  suspect  that  the  bladder  is  distended ;  it  does  not  occur 
when  the  bladder  is  empty  ;  it  is  not  sufficient  to  prevent  it  from  being 
distended.  Indeed,  I  do  not  now  recollect  any  condition  but  overdis- 
tension that  causes  it.  Retention  of  faces  is  not  productive  of  so  great 
trouble  as  the  other,  but  is  attended  with  more  less  inconvenience. 

Great  pelvic  distress,  with  stillicidium  urinss,  are  almost  characteristic 
of  retroflexion  or  retroversion,  when  recent  pregnancy  exists. 


EETEOVEESION   AND    EETROFLEXION    OF    THE    UTEEUS.         541 

Diagnosis. 

This  is  usually  not  difficult.  The  first,  a  very  important  consid- 
eration, is  the  existence  of  pregnancy.  Upon  making  vaginal  examin- 
ation, immediately  upon  introducing  the  finger  it  comes  in  contact 
with  a  tumor.  The  pelvis  is  filled  up  by  it  in  the  posterior  and  lower 
part  so  that  the  finger  is  directed  upward  and  forward.  Very  high  up 
the  vaginal  cavity  is  quite  small  from  pressure,  at  its  extremity ;  in 
contact  with  the  pubis  is  the  os  tincse,  very  firmly  held  in  its  place. 
The  tumor  is  round,  elastic,  and  smooth ;  not  so  hard  as  fibrous  tumors, 
more  central  than  ovarian,  and  more  uniformly  round  than  extra- 
uterine pregnancy.  It  may  be  ascertained  in  most  instances,  also, 
that  the  tumor  is  larger  toward  the  sacrum  than  the  symphysis. 

Termination. 

When  left  to  itself  retroversion  may  terminate  in  abortion,  when 
the  contents  of  the  uterus  will  be  expelled  and  the  symptoms  thus 
relieved ;  or  the  bladder  may  be  ruptured,  the  urine  being  discharged 
in  the  peritoneal  cavity,  causing  painful  death ;  or  the  uterus  may  be 
ruptured,  and  its  contents  discharged  in  the  cavity  of  the  peritoneum, 
giving  rise  to  fatal  peritonitis ;  or  the  foetus  and  its  membranes  may 
be  surrounded  by  fibrinous  material,  the  patient  recover,  and  these 
substances  remain  there  enveloped;  or,  inducing  local  suppurative 
inflammation,  be  discharged  by  exulceration.  Sometimes  the  tenes- 
mus becomes  so  great  as,  by  the  violence  of  the  efforts,  to  break 
through  the  posterior  walls  of  the  vagina  and  uterus,  and  discharge 
the  contents  through  the  vulva  from  this  artificial  opening.  Inflam- 
mation sometimes  arises  without  being  initiated  by  any  of  these  dis- 
astrous accidents,  and  less  suddenly  causes  the  death  of  the  patient. 
I  think  there  can  be  no  doubt  but  that  there  are  very  rarely  cases  of 
spontaneous  reposition,  recovery,  and  completion  of  the  term  of  ges- 
tation. 

The  prognosis  is  unqualifiedly  bad  if  left  to  nature,  but  equally 
favorable  if  intelligently  treated  at  the  proper  time. 

Treatment. 

The  main  thing  to  be  done  is  to  replace  the  uterus.  This  can  very 
generally  be  accomplished.  The  attempt  should  not  be  delayed,  as 
the  uterus  is  constantly  increasing  in  size,  and  the  impaction  becom- 
ing more  certainly  greater,  increasing  the  difficulties  as  well  as  dangers. 
To  facilitate  the  replacement,  the  bladder  should  be  emptied  by  the 
catheter  when  practicable,  and  the  fseces  removed  from  the  rectum. 
This  takes  away  some  of  the  obstacles.  Sometimes  the  urethra  is  so 
tortuous  in  its  course,  and  the  walls  compressed  so  completely  to- 
gether, that  a  catheter  will  not  enter  the  bladder.  An  elastic  catheter 
will  sometimes  pass  the  obstruction  when  the  metallic  will  not;  which- 


642  DISPLACEMENTS   OF   THE  UTERUS. 

ever  we  may  use  should  be  urged  forward  with  the  utmost  gentleness, 
bearing  in  mind  the  great  danger  of  perforating  the  attenuated 
urethra.  The  patient  should  be  placed  upon  her  knees  and  chest,  or 
on  the  left  side,  with  the  left  arm  behind  her,  the  thighs  strongly 
flexed,  and  the  right  drawn  up  close  to  the  abdomen  and  thrown  for- 
ward. She  should  be  placed  on  a  table  or  the  edge  of  a  bed,  so  that 
the  genital  organs  are  easily  controlled  by  the  operator.  In  this  posi- 
tion we  may  often  succeed  in  replacement  by  the  hand  alone.  The 
right  hand  should  be  well  lubricated,  and  all  the  fingers  be  intro- 
duced into  the  vagina,  so  that  the  palmer  surface  is  turned  to  the 
sacrum.  The  tumor  is  thus  pushed  up  very  gently  and  slowly,  with 
the  pulps  of  the  fingers  pressed  closely  upon  the  face  of  the  sacrum, 
as  high  as  the  hand  may  be  made  to  reach.  There  are  not  many  cases 
in  which  the  fingers  will  fail  to  carry  the  fundus  above  the  promon- 
tory of  the  sacrum.  When  thus  elevated  it  suddenly  starts  up  and 
assumes  the  normal  position.  If,  however,  the  fingers  do  not  reach 
high  enough  for  this  purpose,  a  collapsed  gum-elastic  bag  or  bladder 
may  be  carried  up  between  the  fingers  and  the  uterus,  and,  when 
elevated  as  much  as  we  can  reach,  the  bag  may  be  inflated  sufficiently 
to  raise  the  uterus  high  enough.  I  have  succeeded  in  all  the  cases  I 
have  tried  with  this  method,  and  I  think,  when  the  impaction  is  not 
so  great  as  to  preclude  dislodgment,  that  it  will  almost  invariably 
succeed.  Some  surgeons  recommend  the  introduction  of  the  empt}'' 
bag  into  the  rectum,  and  inflating  it  there,  and  pushing  it  up ;  others 
introduce  a  drumstick,  with  the  end  cushioned  and  lubricated,  into 
the  rectum,  and,  pressing  it  against  the  uterus,  elevating  it  in  that 
way.  Again,  an  instrument  is  used  not  unlike  two  drumsticks,  some- 
what curved,  attached  together.  The  attachment  confines  the  ends 
very  near  each  other.  The  end  of  one  of  the  branches  goes  into  the 
rectum,  and  the  other  into  the  vagina.  Thus  arranged  they  pass  up 
and  carry  before  them  the  uterus.  These  expedients  are  very  sure, 
but  rough,  and  not  a  very  safe  means  of  arriving  at  the  results.  I 
think  as  much  force  in  a  proper  direction  can  be  applied  by  the 
fingers  and  elastic  bag  as  it  is  judicious  to  employ  in  such  cases. 
There  are  other  methods  of  proceeding,  but  I  do  not  think  it  neces- 
sary to  mention  any  other,  as  these  will  suffice  when  reduction  is 
practicable. 

In  all  these  efforts  to  elevate  the  fundus  we  may  fail,  and  then  we 
may  evacuate  the  uterus.  This  can  generally  be  done  by  passing  a 
bent  probe  through  the  mouth  of  the  uterus  far  enough  to  rupture  the 
membranes,  and  permit  the  escape  of  the  liquor  amnii.  This  being 
done,  abortion  will  soon  ensue.  Puncturing  the  uterus  with  a  trocar 
through  the  vaginal  wall  I  can  conscientiously  only  mention,  for  I 
can  hardly  think  the  operation  ever  commendable  or  necessary.  The 
cervix  is  probably  hardly  ever  so  inaccessible  but  that  some  form  of 
bent  instrument  can  be  made  to  enter  it. 


CHAPTER    XXXIII. 

DISPLACEMENTS  OF  THE  UTERUS  (Continued). 

Inversion  of  the  Uterus. 

Inversion  is  the  turning  of  the  uterus  inside  out,  with  the  fundus 
down  and  the  cervix  up,  a  reversion  of  its  surfaces  and  ends.  It  is 
partial  or  complete.  When  partial,  the  fundus  is  depressed  in  all 
degrees,  from  a  mere  indentation  to  a  considerable  protrusion  through 
the  cervix  and  os  uteri.  The  depression  of  the  fundus,  or  partial  in- 
version, passes  into  complete  when  the  whole  organ,  fundus,  body, 
and  neck,  have  passed  through  the  mouth,  and  hang  down  below  it. 
It  presents  a  recent  and  a  chronic  form.  The  recent  may  be  regarded 
as  extending  through  the  first  two  weeks ;  after  which,  the  circum- 
stances and  condition  of  the  uterus  and  patient  become  what  they  re- 
main in  the  future,  however  long  it  lasts.  The  uterus,  in  that  time, 
has  been  condensed  by  contraction  and  involution  to  such  an  extent 
as  to  make  the  case  permanent  and  difficult  of  change,  except  to  dimi- 
nution and  further  condensation.  Inversion  almost  invariably  occurs 
•  anterior  to  or  at  the  time  of  the  removal  of  the  placenta,  but  several 
hours,  and,  in  very  rare  cases,  several  days  may  elapse  before  it  is 
complete  and  discovered ;  for  it  is  quite  probable  that  in  these  in- 
stances partial  inversion  or  greater  or  less  depression  of  the  fundus 
had  existed  from  the  time  of  delivery.  It  is  believed  by  different 
parties  that  there  are  two  modes  observed  in  the  process  of  inversion. 
Sometimes  the  fundus  is  indented  or  depressed  in  the  cavity  of  the 
body  like  the  bottom  of  a  "junk  bottle,"  the  depression  rapidly  or 
slowly  increasing  until  it  is  completely  down.  At  others,  the  whole 
of  the  fundus,  and,  more  or  less,  the  whole  of  the  body,  are  firmly 
contracted,  while  the  cervix  remains  flabby  and  relaxed.  In  this  con- 
dition a  slight  amount  of  abdominal  tenesmus  will  drive  the  con- 
tracted part  down  through  the  relaxed  cervix ;  and  thus  initiated,  it 
requires  but  a  continued  action  of  the  fibres  of  the  organ  and  abdomi- 
nal muscles  to  finish  the  process.  The  causes  of  inversion  are  not 
always  obvious,  as  cases  have  occurred  under  circumstances  when 
least  expected  from  any  discoverable  reasons,  and  inversion  fails  to 
be  brought  about  by  circumstances  that  are  usually  enumerated  as 
sufficient.  We  occasionally  meet  with  instances  that  have  no  history, 
and  neither  patient  nor  physician  can  give  us  a  clear  idea  of  the  time 
or  manner  of  the  occurrence.  Such  a  case  was  a  subject  of  litigation 
in  this  city  a  few  years  since.     And  other  cases  are  recorded  in  virgins, 


544  DISPLACEMENTS   OF   THE    UTERUS. 

and  consequently  referred  to  congenital  origin.  In  a  large  majority, 
however,  we  may  trace  the  history  back  to  accouchement.  The  pre- 
disposing causes  are  enlargements  and  partial  or  complete  passiveness 
of  a  part  or  the  whole  of  the  muscular  fibres  of  the  uterus.  These 
are  the  conditions  in  confinement  at  full  term,  or  abortion  or  prema- 
ture labor,  also  enlargement  from  hydatids,  hydrometra,  tumors,  etc. 
When  the  uterus  is  thus  enlarged  and  lax  after  a  greater  or  less  loss 
of  its  contents,  traction  on  the  cord  or  j^lacenta,  or  contained  tumor, 
or  injudicious  or  accidental  pressure  on  the  fundus  by  the  hand  of 
some  person,  or  the  action  of  the  abdominal  muscles  thrusting  the 
contents  of  the  abdomen  downward  upon  that  part  of  the  organ,  it 
may  be  inverted.  It  is  possible,  I  think,  also,  that  powerful,  irregular 
action  of  the  fibres  of  the  uterus  may  cause  the  initiation  and  comple- 
tion of  the  process  of  inversion.  It  is  then  said  to  be  spontaneous. 
The  weight  of  the  placenta,  or  the  contraction  to  expel  a  polypus, 
may  commence  inversion,  and  even  complete  it.  The  irregular  con- 
tractions that  result  in  inversion  may  commence  before  the  expulsion 
of  the  child.  After  the  liquor  amnii  has  been  discharged  for  a  long 
time,  the  uterus  contracts  to  suit  the  inequalities  of  the  fetal  surface, 
the  globular  shape  of  the  organ  being  replaced  by  inequalities  in  a 
number  of  places.  Much  is  yet  to  be  learned  on  this  subject.  It 
would  seem  clear  from  statistics  brought  forward  by  Drs.  West  and 
McClintock  that  it  is  exceedingl}^  rare,  if  it  ever  occurs,  under  good 
management  of  labor  cases.  It  has  not  been  encountered  in  ^^atients 
confined  in  the  London  Maternity  Charity,  nor  the  Lying-in  Hospi- 
tal of  Dublin  in  140,000  cases.  The  student  is  not  to  consider  from 
this, that  it  is  impossible  for  it  to  occur  in  the  hands  of  the  ablest  of 
accoucheurs. 

Symptoms. 

Usually  these  are  appalling  in  the  extreme.  "Without  warning  the 
patient  is  seized  with  faintness,  coldness  of  the  extremities,  sense  of 
great  prostration,  rapid  and  very  feeble  pulse,  oppression  about  the 
heart,  copious  perspiration,  hurried  breathing,  often  vomiting,  ring- 
ing in  the  ears,  and  blindness.  Soon  these  symptoms  increase,  until 
the  patient  lies  in  a  profound  state  of  collapse,  indifferent  to  every- 
thing transpiring  around  her,  or  throwing  herself  in  every  direction 
in  paroxysms  of  agony  inexpressible.  This  condition  of  collapse  is 
not  always  the  result  of  copious  hemorrhage,  but  seems  to  be  of 
nervous  origin,  a  shock  not  unlike  that  caused  by  severe  accidents, 
as  falls,  strokes,  etc.  But,  generally  mingled  with  this  sort  of  im- 
pression, there  is  profound  exhaustion  from  loss  of  blood.  From  this 
state  of  collapse  the  patient  may  very  slowly  rall}^  until  she  enters  a 
tedious  and  imperfect  convalescence.  Or,  in  the  cases  where  the  ex- 
haustion from  hemorrhage  is  added  to  the  great  depression  of  the 
shock,  the  patient  may  be  overwhelmed,  and  in  a  hour,  or  very  few 


INVERSION    OF    THE    UTERUS.  545 

hours,  her  saffermgs  end  in  death.  Imperfect  recovery  from  the  great 
effects  of  the  first  shock  may  enable  tlie  patient  to  live  for  several  days, 
and  at  last,  in  five  to  ten  days,  die.  In  case  the  patient  recovers  from 
the  first  symptoms,  after  some  weeks  she  may  regain  a  fair  degree  of 
health,  and  retain  it,  or  even  improve,  until  lactation  gives  place  to 
ovulation,  or  until  this  last  function  supervenes  upon  the  first.  The 
first  menstrual  discharge  is  preceded  by  copious  mucous  evacuation, 
and  when  the  menses  begin  they  are  more  than  ordinarily  profuse, 
and  generally  before  they  cease  amount  to  prostrating  hemorrhage. 
This  hemorrhage  is  repeated  monthly,  more  frequently,  or  is  continu- 
ous, while  the  leucorrhoeal  discharges  become  very  profuse.  Func- 
tional derangement  of  other  and  important  organs  enters  the  list  of 
morbid  impressions;  the  bowels  are  constipated,  the  heart  palpitates, 
the  stomach  cannot  digest  with  its  former  vigor  and  completeness,  the 
head  aches,  the  eyes  become  weak;  the  disposition  of  the  patient 
changes ;  the  memory  fails  her ;  she  is  pale,  cold,  and  anaemic ;  in 
short,  she  enters  a  decadence  that  is  continuous,  until,  after  several 
months,  or  a  few  years,  she  is  exhausted  and  dies.  Although  this  is 
the  course  usually  pursued  by  cases  of  inversion,  it  must  be  remem- 
bered that  there  is  a  class  of  them  in  which  the  patients  do  not  suffer 
even  much  inconvenience,  and  their  condition  is  discovered  only  by 
accident  during  their  life,  or  on  the  dissecting-table. 

Diagnosis. 

.  When  the  symptoms  present  themselves  so  as  to  awaken  suspicion, 
the  diagnosis  of  recent  cases  may  be  made  out  quite  clearly,  by  the 
descent  of  a  tumor  into  or  entirely  through  the  vagina,  and  the  ab- 
sence of  the  uterine  globe  above  the  symphysis  pubis.  The  diagnosis,, 
after  a  few  days  or  weeks  have  elapsed,  and  the  case  becomes  chronic,, 
is  not  quite  so  simple  and  ready.  The  tumor  is  felt  in  the  vagina,. 
and  is  more  sensitive  than  polypus.  It  is  easily  surrounded  by  the 
fingers,  and  by  introducing  two  fingers  in  the  vagina  to  the  upper 
end  of  the  tumor,  the  depression  formed  by  the  junction  of  the  vagina 
and  uterus  may  generally  be  easily  surveyed.  If  this  is  not  entirely 
satisfactory,  the  sound  should  be  introduced  into  the  vagina  before 
the  fingers  are  withdrawn,  and,  guided  by  them,  be  made  to  sink  as 
deeply  into  this  depression  as  it  will  go  without  too  much  force..  If 
the  uterus  is  inverted,  the  probe  will  not  pass  beyond  the  fingers  any 
distance,  but  if  the  vaginal  tumor  be  a  polypus,  the  sound  will  pass 
up  at  some  point  some  inches  above  the  fingers  into  the  uterine 
cavity.  Traction  often  causes  the  depression  between  the  inverted 
body  and  the  os  to  disappear.  A  polypus,  as  Reamy  has  pointed  out, 
may  often  be  rotated,  while  the  uterus  cannot.  The  operator  may 
test  the  position  of  the  uterus  in  another  way,  by  introducing  the 

35 


546  DISPLACEMENTS    OF   THE    UTERUS. 

finger  high  up  into  the  rectum,  so  that  the  end  may  reach  ahove  the 
tumor,  and  retaining  it  there,  he  may  pass  a  catheter  or  sound  into 
the  bladder,  and  approximate  the  two ;  if  the  womb  is  in  place,  its 
thickness  will  be  perceived  interposed  between  the  two,  but  if  inverted, 
the  extremity  of  the  catheter  can  be  brought  down  upon  the  finger, 
with  nothing  but  the  membranous  walls  of  the  bladder  and  rectum 
intervening. 

Prognosis. 

No  more  serious  complication  of  labor  can  occur  than  inversion  of 
the  uterus.  The  danger  is  great  and  imminent;  in  a  considerable 
majority  of  cases  proving  fatal,  the  patient  dies  within  a  few  hours. 
Mr.  Crosse  says :  "  In  seventy-two  out  of  one  hundred  and  nine  fatal 
cases,  the  patient  died  within  a  few  hours,  eight  of  the  remainder 
within  a  week,  and  six  more  within  four  weeks;  another  at  five 
months,  the  result  of  an  operation  which  had  an  unsuccessful  issue, 
one  died  a't  eight  months,  three  at  nine  months,  and  the  others  at 
various  periods  of  from  one  to  twenty  years."  (  West.)  Death  in  the 
first  place,  soon  after  delivery,  seems  to  be  the  result  of  rapid  exhaus- 
tion of  the  vital  forces  by  the  terrible  shock  to  the  nervous  system  and 
the  profuse  hemorrhage  that  often  complicates  it.  Death  in  subse- 
quent times,  however  remote  in  the  chronic  form,  is  brought  about  by 
impairment  of  the  vital  functions  by  the  same  means,  operating  more 
slowly,  but  as  surely.  The  patient  dies  from  exhaustion  in  both 
forms.  Accordingly,  we  find  that  w^hile  inflammation  has  something 
to  do  in  afi"ecting  the  issue  in  rare  instances,  those  cases  in  which 
there  is  no  uncommon  hemorrhage  or  leucorrhceal  discharge  last 
longest,  and  sometimes  do  not  prove  fatal  at  all,  the  patient  enjoying 
fair  health  for  many  years.  I  know  one  patient,  fifty-six  years  of  age, 
whose  uterus  was  inverted  sixteen  years  ago,  and  yet  remains  in  that 
condition,  as  I  have  verified  by  examination,  who  is  in  the  enjoyment 
of  as  good  health  as  the  majority  of  women  of  her  time  of  life. 

Treatment. 

The  management  of  recent  cases  will  be  the  easier  the  sooner  after 
the  accident  it  is  commenced.  Its  reduction  is  generally  successfully 
accomplished  within  the  first  hour  or  two  if  intelligently  attempted. 

It  is  more  difficult  as  time  elapses,  but  it  should  never  be  considered 
impracticable  until  proper  and  persevering  eff'orts  have  been  made. 
The  first  item  for  consideration  and  action  is  to  dispose  of  an  attached 
placenta  when  the  uterus  has  not  detached  it  before,  during,  or  after 
its  descent.  If  the  placenta  is  wholly  adherent,  its  attachment  should 
in  nowise  be  interfered  with  until  the  uterus  is  returned  to  its  former 
position ;  but  if  it  is  partially  detached,  it  should  be  immediately 
separated  by  gently  "  i:)eeling  "  it  off  with  the  fingers.     This  instruc- 


INVERSION    OF   THE    UTERUS.  547 

tion  has  reference  solely  to  the  prevention  or  lessening  the  amount  of 
hemorrhage.  If  the  placenta  is  attached  throughout,  the  hemorrhage 
will  be  trifling ;  if  partially  separated,  the  condition  most  likely  to  be 
accompanied  with  fatal  hemorrhage  exists — relaxation  of  the  uterus 
and  partial  separation  of  the  placenta.  It  is  well  known  that  suffi- 
cient contraction  of  the  uterus  will  separate  the  placenta,  and  when 
not  contracted  enough  to  do  so,  it  is  in  too  lax  a  state  for  us  to  desire 
its  detachment.  If  the  placenta  is  partially  separated,  the  completion 
of  it  by  the  fingers,  as  in  the  case  when  included  in  the  uterus,  will 
enable  and  stimulate  this  organ  to  contraction,  and  thus  to  the  sup- 
pression of  the  hemorrhage.  I  do  not  think  the  question  of  conve- 
nience of  return,  or  the  possibility  of  being  foiled  in  the  reduction  by 
the  continued  attachment,  should  be  entertained.  The  want  of  con- 
traction enough  to  throw  off  the  placenta  is  an  evidence  of  such  pro- 
found inertia  as  to  insure  easy  reduction  of  the  uterus. 

It  being  decided  what  course  to  pursue  with  the  placenta,  imme- 
diate efforts  should  be  made  to  revert.  And  before  beginning  these 
efforts,  we  should  remind  ourselves  of  some  facts  in  the  case  that  are 
apt  to  be  lost  sight  of  in  the  hurry  and  confusion  of  such  an  appall- 
ing occasion.  One  fact  is,  that  immediately  after  the  occurrence  of 
the  accident,  the  uterus  is  in  the  same  flaccid  condition  in  which  it 
was  incapable  of  resisting  the  action  of  the  cause ;  another  is,  that  it 
soon  begins  to  contract,  becomes  firm,  and,  consequently,  more  diffi- 
cult to  affect  by  counter  influences ;  and  a  third,  that  the  more  the 
uterus  is  stimulated,  by  handling  or  otherwise,  the  sooner  and  more 
firm  the  contraction  becomes,  and,  consequently,  the  greater  difficulty 
in  reduction. 

No  operator  has  complained  to  us  of  the  bulk  being  too  great  to 
return,  but  all  of  the  resistance  caused  by  contraction.  The  experi- 
ence of  Dr.  Meigs  is  conclusive  on  this  point.  He  found  that  upon 
attempting  to  reduce  the  size  of  the  uterus,  by  squeezing  it  to  expel 
the  blood,  he  caused  it  to  contract,  and  it  became  so  hard  as  to  resist 
his  efforts  to  push  it  up  within  the  os ;  but  as  soon  as  he  pressed 
upon  the  fundus  he  would  depress  it,  or  rather  elevate  it,  until,  by 
continuing  pressure,  he  made  it  ascend  first  into  the  body,  and 
through  it  into  the  neck,  and  finally  up  to  its  proper  place;  Dr. 
White,  of  Buffalo,  although  he  did  not  mention  with  the  same  dis- 
tinctness the  effects  of  the  two  sorts  of  pressure,  was  enabled,  by  in- 
denting first  and  then  following  up  the  vantage,  finally  to  push  the 
fundus  up  the  same  way  through  the  os  and  body  of  the  uterus  after 
he  had  in  vain  tried  to  reduce  it  by  squeezing,  etc.  Dr.  White's  case 
was  reduced  in  this  way  eight  days  after  delivery.  And  I  must  be 
allowed  to  express  the  opinion,  that  it  increases  the  difficulties  in 
recent  cases  of  inversion  to  try  to  lessen  the  bulk  of  the  uterus.     A 


548  DISPLACEMENTS    OF   THE   UTERUS. 

great  bulk  indicates  a  flabby,  reducible  state,  and  is  favorable  to 
success  instead  of  otherwise.  Do  not  squeeze  the  uterus  to  lessen  its 
size  in  these  cases. 

The  two  cases  I  have  referred  to,  of  Drs.  White  and  Meigs,  so  in- 
telligently and  deliberately  observed,  and  so  clearly  described,  furnish 
us  with  more  intelligible  means  of  arriving  at  correct  ideas  of  the 
steps  by  which  inversion  of  the  uterus  is  reversed,  than  any  I  am  able 
to  find  on  record.  They  both  concur  in  showing  the  usefulness  of  one 
hand  in  the  vagina  to  steady  the  uterus,  and  direct  the  force  applied 
to  the  fundus  by  the  other  hand,  and  the  injurious  effects  of  compress- 
ing the  body  of  the  organ.  The  most  appropriate  mode  of  operating 
in  recent  inversion,  therefore,  is  to  introduce  the  left  hand  into  the 
vagina  behind  the  uterus,  while  with  the  fingers  of  the  right  the  fundus 
is  indented,  and  gently,  but  steadily  and  perseveringly,  reverted  en- 
tirely above  the  os  and  cervix,  until  it  assumes  the  globular  shape 
and  proper  position  above  the  symphysis.  If  the  fingers  of  the  right 
hand  cannot  be  used  to  advantage,  or  are  too  weak  to  accomplish  the 
desired  elevation,  we  may  use  a  large  elastic  rectum  bougie,  an  instru- 
ment resorted  to  by  Dr.  White,  or  one  by  Dr.  Beers,  shaped  like  the 
end  of  a  walking-cane,  with  a  round  smooth  head  upon  a  staff.  The 
indentation  and  elevation  may  be  more  efficiently  effected  by  this 
latter  instrument,  perhaps. 

The  fact  cannot  be  too  forcibly  impressed  upon  our  minds,  in  un- 
dertaking this  operation,  that  gentle  firmness  is  the  proper  expression 
for  the  force  to  be  employed.  Perseverance,  instead  of  violence,  is 
both  more  certain,  successful,  and  secure,  in  overcoming  the  resist- 
ance of  muscular  fibre  anywhere.  This  is  especially  true  with  the 
uterus,  the  strongest  muscle  in  the  body.  As  nearly  as  may  be,  we 
should  act  in  the  absence  of  uterine  contractions.  During  and  after 
the  time  we  are  attempting  the  return  of  the  organ,  the  strength  of 
the  patient  must  be  supported  by  stimulants,  tonics,  and  nutrients. 
Brandy  will,  perhaps,  serve  best  to  restore  the  circulation  and  heat ; 
it  may  be  aided  by  the  use  of  the  aromatic  spirits  of  ammonia  and 
laudanum.  In  addition  to  the  stimulant  and  supporting  influence 
which  laudanum  exerts,  it  allays  the  irritable  condition,  so  frequently 
present,  of  the  stomach,  the  uterus,  etc.  After  the  urgency  of  the 
symptoms  has  passed  by,  the  tincture  of  iron,  quinia,  beef  essence, 
and  nutritious  diet  generally,  will  be  necessary  to  restore  the  im- 
paired condition  of  the  vital  energies.  The  energy  with  which  the 
stimulants  are  to  be  urged  during  the  shock  must  be  regulated  by 
the  urgency  of  the  danger.  Large  doses  of  brandy,  laudanum,  and 
spirits  of  ammonia  will  not  only  be  borne,  but  often  be  called  for  to 
meet  the  symptoms. 


INVERSION    OF   THE   UTERUS.  549 

The  Treatment  of  the  Chronic  Form, 

Is  palliative  and  curative.  The  palliative  is  for  the  purpose,  as  far 
as  possible,  to  check  the  drain  which  is  so  constantly  exhausting  the 
patient,  to  support  the  system  as  well  as  we  can,  and  to  use  any  other 
means  suggested  by  the  circumstances  for  the  relief  of  distressing 
symptoms. 

The  hemorrhage  is  from  the  mucous  membrane  of  the  uterus,  its 
outer  surface  as  it  lies  in  the  vagina,  as  also  the  profuse  mucous  dis- 
charge. I  think  much  may  be  done  to  moderate,  if  not  stop,  these 
evacuations  by  astringents  introduced  into  the  vagina,  so  as  to  sur- 
round and  lie  in  contact  with  the  uterus.  Pledgets  of  lint,  saturated 
with  the  persul.  of  iron,  passed  up  into  the  vagina,  and  allowed  to 
remain  on  the  bleeding  surface  of  the  uterus  until  the  bleeding  ceases, 
will  be  of  great  service.  The  tinct.  ferri  chlorid.  on  lint  is  an  excellent 
application  for  the  same  purpose.  Other  astringents  may  be  tried  in 
the  same  manner.  If  these  should  fail,  the  vagina  may  be  tamponed 
fully  with  cotton,  dipped  in  astringents  or  not  as  the  physician  may 
think  best.  Severe  paroxysms  of  hemorrhage  should  be  carefully 
treated  in  this  way  until  they  terminate,  it  being  desirable  to  save  as 
much  blood  as  possible.  It  is  not  necessary  to  suggest  to  the  intelli- 
gent reader  the  necessity  of  rest  in  the  horizontal  position.  Between 
these  paroxysms  the  patient  should  use  astringent  injections  of  con- 
centrated strength,  saturated  solutions  of  alum,  acetate  of  lead,  tannin, 
etc.,  with  a  view  to  condense  the  mucous  membrane,  and  render  it 
less  vascular,  and  in  this  way  abate  the  urgency  of  the  losses.  The 
tinct.  ferri  chl.,  one  part  to  four  of  water,  twice  or  thrice  a  day,  will 
have  an  efficient  astringent  effect  upon  the  uterus.  When  the  organ 
extends  through  the  vulva,  it  is  irritated  by  contact  with  the  limbs 
and  clothing,  and  it  is  very  desirable  to  return  it  into  the  vagina,  and 
keep  it  within  that  cavity.  The  gum-elastic  air-pessary,  supported 
by  a  T  bandage,  will  keep  it  in  the  vagina,  and  may  render  it  more 
easy  of  a  radical  cure,  by  reduction  or  reversion.  I  would  urge  the 
attendant  to  personal  attention  to  this  treatment,  to  such  an  extent, 
at  least,  as  is  necessary  to  have  it  efficiently  tried.  Very  few  patients 
have  the  intelligence  to  appreciate  the  importance  of  it,  or  to  know 
when  proper  trial  of  it  has  been  made. 

The  radical  treatment  has  for  its  objects  either  a  restoration  of  the 
organ  or  its  amputation  and  removal.  So  far  as  we  can  judge, 
although  both  operations  are  attended  with  danger,  that  of  amputa- 
tion the  more.  .  And  I  think  it  clearly  the  duty  of  the  practitioner, 
when  driven  to  a  choice  between  the  two,  to  give  preference  to  at- 
tempts at  restoration.  We  have  not  only  greater  safety  as  an  argu- 
ment in  favor  of  it,  but  successful  restoration  reinstates  the  patient 
in  all  her  sexual  capacities,  while  amputation,  if  not  diastrous  in 


550  DISPLACEMENTS    OF   THE   UTERUS. 

other  respects,  renders  her  forever  sexually  neuter.  It  is  to  be  hoped 
that  before  long  the  operation  of  amputation  will  be  regarded  as  un- 
justifiable, because  of  the  certainty  of  restoration.  Great  improve- 
ment in  our  means  and  the  mode  of  effecting  this  must  be  made, 
however,  before  this  conclusion  can  be  reached.  There  is  no  longer 
room  for  doubting  that  restoration  of  the  inverted  uterus  occurs  spon- 
taneously, I  think  it  is  proven  by  the  case  of  Dr.  Hatch,  published 
in  Dr.  Meigs's  Obstetrics.  The  case  of  Madame  Beauchardat,  pub- 
lished by  Baudelocque,  is  also,  I  think,  conclusive  on  the  point  of 
restoration.  Other  cases,  less  clearly  and  circumstantially  reported, 
may  be  found  scattered  through  medical  literature  for  the  last  cen- 
tury. There  are  two  methods,  if  they  may  be  so  denominated,  that 
have  been  successful  in  reducing  chronic  inversion  of  the  uterus. 
Two  representative  cases  are  published  in  the  American  Journal  of 
Medical  Sciences  for  July,  1858  ;  one  by  Professor  Wliite,  of  Buffalo  (it 
was  his  second  case),  and  one  by  Dr.  Tyler  Smith,  of  London.  It  will 
be  observed,  by  examining  the  reports  of  these  cases,  that  the  restora- 
tion began  by  the  cervix  passing  through  the  os  uteri  first,  then  the  . 
body,  and  finally  the  fundus.  This  is  different  from  what  I  think  is 
the  common  mode  of  restoration  in  recent  cases.  The  operation  for 
reversion  in  Dr.  White's  second  case  was  completed,  we  are  led  to 
suppose,  in  something  more  than  an  hour,  and  at  one  sitting.  The 
uterus  had  been  inverted  five  months.  Dr.  White  operated  by  in- 
troducing the  hand  into  the  vagina  while  the  patient  was  in  a  state 
of  anaesthesia  from  chloroform,  squeezing  the  uterus  so  as  to  lessen 
the  size  as  much  as  possible,  and  at  the  same  time  pressing  the  organ 
upwards  by  means  of  the  large  rectum  bougie.  Success  followed  a 
somewhat  protracted  manipulation.  The  uterus  was  restored  by  the 
lips  of  the  OS  uteri  beginning  to  fold  outward,  and  the  neck  to  pass 
up  through  this  opening,  next  the  body,  and  afterwards  the  fundus. 
There  is  nothing  in  this  case  said  about  the  fundus  being  indented 
from  beginning  to  end.  This  is  no  more  than  might  be  expected  by 
considering  the  anatomical  circumstances.  The  fundus  and  corpus 
uteri  are  firmer  and  more  solid  than  the  cervix,  and  hence  less  likely 
to  yield  to  the  same  amount  of  force.  The  force  applied  to  the  fundus, 
when  the  organ  is  strongly  pressed  upward,  acts  more  efficiently  upon 
the  cervix  than  any  other  part,  from  the  fact  that  the  vagina,  attached 
all  around  the  mouth,  has  not  merely  the  effect  of  resisting  the  up- 
ward pressure  of  the  uterus,  but,  being  upon  the  outer  surface,  it  ini- 
tiates and  keeps  up  the  funnel-shape  expansion  of  the  os  necessary  to 
permit  the  other  parts  to  pass  through  it,  as  well  as  to  draw  it  down 
over  the  part  entering  it  from  below. 

I  believe  that,  in  some  respects,  this  is  the  best  manner  of  operating 
for  immediate  restoration,  yet  one  thing  done  seems  to  me  to  be  super- 
fluous, if  not  mischievous,  viz.,  the  squeezing  the  uterus.     Dr.  Sims 


INVERSION   OF   THE    UTERUS. 


551 


recommends  that  the  uterus  be  supported  by  one  hand  above  the 
pubis  to  prevent  too  great  extension  upon  the  vagina.  While  the 
uterus  is  being  pushed  up  from  below,  the  cup-shaped  cavity  formed 
by  the  inverted  cervix  may  be  felt  if  we  forcibly  press  the  fingers 
down  into  the  pelvis  from  above  over  the  pubis.  This  manipulation 
affords  us  valuable  aid  in  forming  our  diagnosis,  while  it  gives  the 
opportunity  of  assisting  in  the  reversion.  The  great  thing  to  be  gained 
is  the  commencement.  After  the  neck  is  one-half  reverted  the  restora- 
tion proceeds  with  more  rapidity  and  ease  than  before  until  complete. 
A  better  instrument  than  the  bougie  used  by  Dr.  White  would  be  a 
cup  on  a  strong  handle,  large  enough  to  safely  lodge  the  fundus  of  the 
uterus.     Dr.  White  now  uses  what  he  calls  the  repositor.    The  figure 


Fig.  271. 


Fig.  272. 


White's  Repohitor. 

shows  its  action  with  sufficient  clearness  to  require  no  extended  ex- 
planation of  its  use.  The  steps  in  the  operation  for  immediate  restora- 
tion are,  first,  to  introduce  the  hand  into  the  vagina,  and,  embracing 
the  uterus  with  it,  hold  the  organ  steady,  with  the  fundus  and  cervix 
nearly  parallel  with  the  axis  of  the  superior  strait;  second,  place  the 
fundus  of  the  uterus  in  the  cup  of  the  instrument  held  by  the  other 
hand,  and  then  press  gently  upward,  increasing  the  firmness  of  it 
until  it  is  as  great  as  the  parts  will  bear  without  violence,  and  con- 
tinuing it  with  such  force  until  the  parts  jdeld  and  pass  up.  The 
time  required  may  be  considerable,  and  it  is  an  object  to  continue  it 
for  a  long  time,  increasing  the  pressure  so  slowly  as  not  to  be  per- 
ceived, except  by  comparing  it  at  considerable  intervals.  The  patient 
should   be  under  the   influence    of  chloroform  to  insensibility,  and 


552  DISPLACEMENTS    OF    THE    UTERUS. 

placed  on  her  back,  with  the  limbs  widely  separated  across  the  bed, 
and  with  the  hips  very  near  it ;  or,  what  would  be  better,  an  operating 
table  of  convenient  height,  about  two  feet  wide  and  five  long.  Greater 
facility  would  be  afforded  for  attendants  by  such  a  table.  The  sur- 
geon should  kneel  or  seat  himself  in  front  of  the  patient,  so  as  to  have 
free  use  of  both  hands  and  perfect  command  of  the  parts. 

The  second  mode  of  restoring  the  inverted  uterus,  as  practiced  by 
Dr.  Tyler  Smith,  is  to  apply  the  force  so  gradually  as  to  require 
several  days  for  the  comjoletion  of  it.  The  means  used  were,  first,  the 
frequent  introduction — I  think  twice  a  day — of  the  hand  into  the 
vagina  to  squeeze  the  uterus ;  and,  second,  to  keep  a  gum-elastic  air- 
bag  distended  in  the  vagina,  which  constantly  pressed  the  fundus 
upward,  certainly,  however,  with  no  great  force.  He  succeeded  in 
restoring  a  uterus  that  had  been  inverted  for  fifteen  years.  With 
proper  apparatus  I  should  very  much  prefer  this  gradual  method,  as 
requiring  less  violence,  being  less  hazardous,  and  perhaps  less  painful. 

A  sufficient  number  of  cases  have  been  successfully  treated  by  this 
means  to  justify  giving  it  a  fair  trial.  Having  succeeded  in  three 
cases  in  reducing  with  the  elastic  bag,  I  am  more  favorably  impressed 
with  its  efficiency  than  Dr.  White  seems  to  be.  The  reduction  was 
effected  in  from  five  to  eight  days,  without  giving  the  patient  pain 
enough  to  interfere  with  her  sleep,  or  causing  her  any  serious  incon- 
venience. Each  day  showed  advances;  the  first,  relaxation  of  the 
rigid  neck ;  the  next,  shortening  of  the  displaced  uterus ;  and  each 
day  after  exhibited  gradual  improvement  until  the  restoration  was 
found  to  be  complete.  I  am  convinced  that  in  many,  if  not  most,  of 
the  simple  cases  of  chronic  inversion  the  reposition  may  be  accom- 
plished by  this  method,  and  I  would  certainly  try  it  before  resorting 
to  the  more  hazardous  and  more  painful  plan  of  Dr.  White.  Success 
with  the  elastic  bag,  however,  requires  a  careful  study  of  each  case, 
and  a  watchful  adaptation  of  the  means.  The  kind  of  instrument  is 
of  much  importance.  The  best  shape,  perhaps,  is  quadrilateral.  It 
should  be  strong  enough  to  bear  considerable  pressure  without  mate- 
rially altering  its  shape,  and  furnished  with  a  tube  and  very  tight 
stopcock.  The  instrument  should  be  distended  with  water  instead 
of  air,  as  there  are  few  that  will  not  permit  air  to  escape  in  greater  or 
less  quantities.  The  chances  of  success  will  be  increased  by  a  firm 
and  well-shaped  perineum  to  support  the  pressure,  and  by  its  own 
elasticity  adding  to  the  efficiency  of  the  instrument.  When  the  peri- 
neum is  deficient,  we  may  compensate  it  by  well-adjusted  mechanical 
support.     The  more  firm  the  tissues  of  the  vagina  the  better  (Fig.  273). 

The  instrument  should  be  introduced  in  an  empty  condition,  and 
placed  well  back  in  the  vagina,  and  the  water  forced  into  it  until 
moderately  distended.  We  must  then  carefully  examine  the  relation- 
nhip  between  it  and  the  uterus,  and  see  that  the  latter  is  pressed  up- 


INVERSION    OF    THE    UTERUS.  553 

ward  in  the  direction  of  the  axis  of  the  superior  strait.  If  this  is  not 
the  case,  we  may  be  able  to  place  the  uterus  in  the  right  position  by 
moving  it  with  the  finger.  If  this  cannot  be  done,  the  bags  should 
be  emptied  and  changed  until  right.  If  the  shape  of  the  instrument 
is  not  properly  adapted  to  the  vagina,  it  should  be  replaced  by  another. 
By  exercising  due  care  in  selecting  and  adjusting  the  instrument,  we 
shall  be  able  to  get  the  force  exerted  in  the  right  direction.  When 
satisfied  that  the  instrument  is  properly  adjusted,  we  should  inject 
water  into  it,  and  distend  it  as  much  as  the  patient  can  bear  without 
decided  pain.  It  will  not  be  necessary  to  remove  it  more  than  once 
in  twenty-four  hours,  but  it  ought  to  be  examined  in  reference  to  the 
degree  oiE"  distension,  and  if  it  should  continue  tense,  and  the  patient 
feels  no  more  discomfort  from  it,  we  ought  to  inject  more  water  until 
the  patient  experiences  slight  uneasiness  from  the  pressure.  Once  in 
twenty-four  hours  the  water  may  be  allowed  to  escape,  and  the  instru- 
ments be  removed,  the  vagina  cleansed,  and  the  parts  thoroughly 
examined.  If  we  are  producing  any  impression  on  the  rigid  cervix, 
the  relaxation  will  be  perceptible  by  the  facility  with  which  the  uterus 
will  move  upward.  The  instrument  should  be  carefully  readjusted 
and  again  distended.  On  the  second  removal  of  the  bag  I  think, 
usually,  we  may  expect  to  discover  decided  progress  in  the  process 
of  restoration.  I  do  not  believe  it  judicious  to  manipulate  and  squeeze 
the  uterus,  with  a  view  to  lessen  the  blood  in  it,  every  time  we  remove 
the  elastic  bag,  and  would  sedulously  abstain  from  anything  of  the 
kind,  believing  that  the  reaction  after  the  withdrawal  of  the  hand 
would  engorge  the  vessels  of  the  organ.  The  daily  removal  of  the  in- 
strument, cleansing  of  the  vagina,  and  readjustment  must  be  continued 
until  the  uterus  resumes  its  proper  position,  or  until  we  find  we  can- 
not succeed  by  this  plan.  Judging  from  my  own  observation,  and  the 
cases  I  have  seen  recorded,  I  should  expect  success  to  follow  between 
the  fifth  and  the  eighth  days.  But  efforts  may  be  continued  much 
longer  than  this,  if  necessary.  As  soon  as  the  fundus  has  passed  into 
the  cervix,  it  will  spontaneously  resume  its  proper  position,  because 
the  resistance  to  its  doing  so  is  removed ;  but  if  this  should  not  occur, 
a  rectal  bougie  may  be  placed  against  it  and  sufficient  pressure  exerted 
to  rectify  it  completely. 

The  pressure  of  this  elastic  bag  when  properly  managed  is  just  the 
kind  desired,  and  the  degree  may  be  made  very  considerable.  When 
the  bag  is  of  the  right  size  and  form,  the  uterus  is  pressed  upward  in 
such  a  manner  as  to  place  the  vaginal  attachments  upon  the  stretch, 
and  cause  them  to  draw  open  the  cervical  cavity,  and  this  tension  is 
increased  by  the  dilatation  of  the  upper  portion  of  the  vagina  in  every 
direction.  It  thus  acts  as  a  dilator  as  well  as  repositor.  And  although 
the  degree  of  pressure  upward  is  not  so  great  as  may  be  made  by  the 
repositor  of  Dr.  White,  or  by  the  hand,  its  steadiness  of  action,  and 


554  DISPLACEMENTS    OF   THE    UTERUS. 

the  great  length  of  time  it  may  be  continued,  more  than  compensate 
in  the  end  for  its  lack  of  violent  force.  We  all  are  acquainted  with 
the  efficiency  of  moderate  but  long-continued  traction  upon  fibrous 
tissue,  in  cases  of  long-standing  dislocation. 

I  will  here  present  a  case  which  has  recently  come  under  my  ob- 
servation : 

December  24:th,  1878. — Mrs.  M.,  Irish,  aged  twenty-six  years,  was 
brought  to  me  with  inversion  of  the  uterus,  which  had  taken  place  at 
the  time  of  her  first  labor,  fourteen  months  before.  I  obtained  a  very 
imperfect  history  of  the  case,  but  so  far  as  I  could  learn  nothing  un- 
usual occurred  during  pregnancy,  and  when  the  labor  began  the 
patient  was  in  the  enjoyment  of  robust  health.  The  first  and  second 
stages  of  labor  were  normal,  and  together  lasted  six  hours.  During 
the  third  stage  hemorrhage  was  alarming,  and  the  succeeding  pros- 
tration very  great.  The  patient  could  give  no  intelligent  account  of 
the  mode  of  delivering  the  placenta,  or  of  the  duration  of  the  third 
stage.  The  only  recollection  of  it  was  that  she  suffered  from  great 
pain  and  weakness.  The  accident  was  not  discovered  at  the  time, 
and  when,  after  the  lapse  of  some  weeks,  the  attention  of  the  prac- 
titioner was  called  to  the  unusual  condition  of  the  contents  of  the 
vagina,  he  said  :  "She  must  have  a  polypus  or  something  else."  He 
either  was  not  aware  of  what  had  occurred  or  did  not  wish  to  have 
the  true  condition  known. 

Astringent  injections  were  used  and  stimulants  and  tonics  given. 

The  patient  gradually  rallied,  and  during  the  first  year  was  seen  by 
a  number  of  physicians,  and  many  opinions  were  expressed  and 
methods  of  cure  tried.  No  benefit  resulting  from  treatment,  she  came 
under  the  care  of  Dr.  White,  of  Bloomington,  who  recognized  the 
true  condition  of  the  patient,  and  made  a  very  judicious  and  prolonged 
effort  to  reduce  the  uterus  by  the  forcible  method  and  failed.  He 
then  advised  her  to  visit  me  for  further  treatment. 

W^hen  she  arrived  she  was  very  ansemic  and  exhausted.  She  was 
constantly  discharging  blood  and  mucus,  and  at  the  time  of  her 
menses  flowed  profusel3^  There  was  great  tenderness  and  sensitive- 
ness of  the  vagina,  uterus,  and  lower  portion  of  the  abdomen.  The 
pulse  was  weak  and  about  one  hundred  to  the  minute.  She  had  a 
poor  appetite  and  was  obstinately  constipated. 

An  examination  confirmed  the  diagnosis  of  Dr.  White.  The  vagina 
was  very  capacious,  and  depending  from  its  roof  was  a  small,  very 
firm  uterus.  The  involution  seemed  to  have  been  carried  beyond  the 
ordinary  degree.  It  was  in  a  state  of  hyper-involution.  It  was  com- 
pletely inverted.  The  labia  could  be  felt  forming  a  thin  border,  com- 
pletely surrounding  the  cervix,  with  the  likeness  of  a  fringe,  the  edge 
pointing  upwards.  The  uterus  was  so  firm  and  condensed  that  it 
resisted  every  effort  to  elevate  it.     It  could  be  drawn  down  somewhat, 


INVERSION    OF   THE    UTERUS. 


555 


bringing  with  it  a  pouch  of  the  upper  wall  of  the  vagina:  There  was 
considerable  sensitiveness  of  the  iliac  and  hypogastric  regions,  but  no 
tumefactions,  induration,  or  other  evidence  of  the  products  of  inflam- 
mation. A  mild  cathartic  was  administered,  followed  by  the  tincture 
of  iron  and  quinine,  and  on  Christmas  day  the  treatment  for  reduc- 
tion was  commenced.  An  elastic  bag,  four  inches  long,  and  when 
distended  three  inches  in  diameter,  with  a  tube  attached,  was  selected 
as  the  main  instrument.  When  collapsed  this  bag  presented  a  quad- 
rilateral shape,  larger  in  the  centre  and  slowly  tapering  towards  the 
ends.  I  selected  a  sac  of  this  shape  because  it  filled  the  vagina  from 
the  vulva  to  the  bottom  of  the  fornix,  and  when  introduced  one  of 
the  faces  reached  the  fundus  in  such  a  manner  that  the  organ  would 

Fig.  273. 


Eeduclion  of  Inversion  by  the  Elastic  Bag. 

not  easily  slide  over  its  sides.  As  the  bag  was  slowly  distended  the 
fundus  produced  a  depression  in  which  it  was  firmly  retained  when 
the  sac  was  filled. 

I  introduced  this  bag,  while  empty,  so  that  it  lay  on  the  posterior 
wall  of  the  vagina,  and  carefully  adjusted  the  dependent  fundus  so 
that  the  body  was  in  a  line  with  the  axis  of  the  superior  strait. 
Water  was  slowly  injected  until  the  distension  produced  a  sense  of 
discomfort.  The  distension  was  kept  up  for  twenty-four  hours,  when 
the  water  was  permitted  to  flow  away.  The  instrument  was  removed 
and  cleansed,  and  again  rej)laced  and  filled.  The  first  time  it  was 
removed  an  evident  softening  of  the  cervix  was  noticeable,  and  the 
body  could  be  pressed  slightly  into  it.     From  day  to  day  the  softening 


556  DISPLACEMENTS   OF   THE   UTERUS. 

and  dilatation  became  greater,  and  upon  the  removal  of  the  instru- 
ment advance  was  ascertainable.  Upon  removing  the  bag,  on  the 
seventh  day,  I  found  that  the  uterus  was  in  a  state  of  complete  inver- 
sion, and  all  progress  seemingly  lost.  With  the  finger,  however,  I 
could  easily  press  the  fundus  entirely  into  the  dilated  cervix,  thus 
assuring  myself  that  the  work  of  reduction  was  almost  complete.  A 
more  careful  adjustment  and  careful  distension  of  the  bag  were 
effected,  and  on  the  removal  of  the  instrument  on  the  eighth  day  it 
was  found  that  the  fundus  had  mounted  to  its  normal  position.  The 
sound  was  introduced  two  and  a  half  inches.  This  patient  improved 
in  strength  and  became  more  comfortable  from  the  commencement  of 
the  treatment  to  the  end.  After  the  first  three  days  she  was  up  during 
a  part  of  the  day,  and  on  the  seventh  and  eighth  was  about  her  room, 
and,  in  addition  to  keeping  her  room  in  order,  gave  her  child  all  the 
attention  it  needed. 

I  have  no  doubt  that  she  was  perfectly  truthful  in  her  assertion 
that  the  treatment  gave  her  no  inconvenience  except  at  the  time  and 
for  a  few  moments  each  time  after  the  adjustment  of  the  instrument. 
There  was  no  time  when  I  felt  the  least  uneasiness  about  the  effects 
of  the  pressure,  or  was  under  the  necessity  of  giving  anodynes  for  the 
relief  of  pain ;  nor  did  the  presence  of  the  instrument  prevent  the  free 
and  comfortable  evacuation  of  bladder  and  rectum.  In  fact,  the 
patient  improved  from  the  time  she  was  placed  under  treatment. 

Notwithstanding  the  important  improvements  of  Dr.  J.  P.  White, 
who  deserves  more  credit  for  his  success  and  teaching  in  inversion 
than  any  other  man,  and  Dr.  Tyler  Smith's  success  in  the  use  of  the 
gum-elastic  bag,  there  will  yet  remain  cases  in  which  the  uterus  can- 
not be  restored  to  its  natural  position  and  relations.  Inversion,  com- 
plicated with  several  fibrous  tumors  of  the  body  or  fundus,  will  resist 
ordinary  methods  of  reduction,  and,  no  doubt,  cases  in  which  the 
causes  of  difiiculty  cannot  be  precisely  discovered  w^ill  occasionally 
be  found  unmanageable.  What  shall  be  done  with  such  ?  The  neces- 
sity for  any  operation  that  involves  the  life  of  a  patient,  already  in 
great  danger,  should  be  clearly  determined  by  the  circumstances  of 
the  case  and  with  ample  counsel.  If  the  patient's  health  is  growing 
worse  and  her  strength  being  exhausted  by  great  discharges  or  per- 
sistent inflammation,  relief  should  be  attempted  at  all  hazard.  If, 
however,  the  woman  is  enjoying  fair  health,  or  if  the  symptoms  that 
usually  harass  her  after  the  accident  of  inversion  are  improving,  any 
operative  procedure  beyond  efforts  at  reduction,  is  not  justifiable. 

In  cases  where  restoration  is  proven  to  be  impossible  by  proper, 
prolonged,  and  repeated  eff'orts,  or  the  uterus  is  so  enlarged  by  morbid 
growths  as  to  make  it  obviously  useless  to  try  reduction,  and  the  con- 
ditions demand  relief,  amputation  is  the  last  resort.  In  a  resume 
found  in  the  American  Journal  of  Obstetrics,  August,  1868,  translated 


INVEESION    OF   THE   UTERUS.  557 

from  the  German,  we  have  fifty-eight  cases  reported  of  amputation  of 
the  inverted  uterus ;  eighteen  terminated  fatally,  forty  recovered. 
This  is  a  large  mortality,  but  probably  the  fatality  will  become  pro- 
portionately less  as  all  the  conditions  of  the  operations  are  improved. 
The  methods  of  amputation  now  practiced  are  essentially  three : 

1.  Ligating  and  allowing  the  ligature  to  remain  until  it  cuts 
through. 

2.  Ligating  to  prevent  hemorrhage,  and  then  amputating  below  the 
ligature  with  the  knife,  scissors,  or  ecraseur. 

3.  Passing  the  ecraseur  or  galvano-cautery  wire  through  the  sub- 
stance of  the  cervix  without  ligating. 

The  ligature,  when  properly  applied,  effectually  prevents  hemor- 
rhage, but  it  is  very  likely  to  cause  inflammation,  also  a  very  formid- 
able occurrence,  and  one  which  is  the  frequent  cause  of  death.  Or  if 
it  remains  long  enough  to  cause  sloughing,  even  of  the  amputated 
stump,  there  may  arise  toxaemia,  resulting  from  the  absorption  of  the 
putrid  substance.  The  Ecraseur  avoids  this  latter  difficulty,  but  I 
should  fear  it  would  be  an  insecure  guarantee  against  hemorrhage  in 
all  cases.  Dr.  Thomas  Hay,  of  Philadelphia,  reports,  in  the  Medical 
and  Surgical  Reporter,  December  2d,  1871,  a  case  in  which  amputation 
was  successfully  performed  by  the  ecraseur  alone.  Dr.  McClintock,  of 
Dublin,  applied  the  ligature  for  forty-eight  hours,  and  then  removed 
the  uterus  by  amputating  with  the  6craseur  in  the  groove  formed  by 
the  ligature.  Practical  demonstration  is  the  only  reliable  guide  in 
important  operations;  we  are  not  supplied,  however,  with  enough  ex- 
amples of  success  by  any  one  procedure  to  justify  us  in  making  a  posi- 
tive choice  between  them. 

It  will  not  be  difficult  to  get  access  to  the  cervix  for  the  purpose  of 
applying  the  ligature  or  amputating.  This  may  be  done  by  drawing 
the  organ  down  to  the  vulva  with  vulsellum  forceps. 

The  galvano-cautery  is  better  than  all  the  above  methods  of  ampu- 
tation. 

The  wire  applied  as  an  ecraseur,  heated  to  a  dull  red  color,  and 
drawn  slowly  through  the  cervix,  will  do  away  with  the  dangers  of 
hemorrhage,  and  leave  no  sloughing  surface  from  which  sepsis  may  be 
generated. 


CHAPTER    XXXIV. 

DISEASED  DEVIATIONS  OF  INVOLUTION  OF  THE  UTEEUS. 

The  uterus  is  very  much  hypertrophied  by  the  processes  of  gesta- 
tion, so  that  after  its  contents  are  expelled  by  labor,  the  organ  weighs 
from  one  and  a  half  to  two  pounds.  An  atrophizing  process,  called 
involution,  serves  to  reduce  the  organ  to  its  original  conditions  in  size 
and  weight. 

Involution  is  a  physiological  change,  as  much  so  as  evolution ;  but 
not  unfrequently  disease  invades  the  tissues  and  renders  it  abortive : 
1.  Causing  it  to  be  temporarily  "  delayed  ; "  2.  To  fall  short  of  comple- 
tion after  it  has  been  commenced  ;  or,  3.  To  proceed  entirely  beyond 
the  limits  compatible  with  the  healthy  functions  of  the  uterus,  reducing 
it  below  its  usual  weight  and  size. 

I  mean  by  the  term  "  delayed  involution  "  to  designate  a  condition 
of  the  uterus  in  which  this  process  does  not  begin  for  a  number  of 
days — from  ten  to  fourteen — after  parturition. 

The  contractions  which  immediately  succeed  and  continue  after 
labor,  by  interrupting  the  circulation  in  the  substance  of  the  uterus, 
initiate  that  process,  and  by  the  end  of  a  fortnight  it  is  half  finished. 
Should  these  contractions  be  rendered  inefficient,  involution  is  at  a 
stand,  the  uterus  remains  large,  the  circulation  too  great  for  safety  to 
the  patient,  and  sufficient  to  keep  up  the  nutrition  in  the  muscular 
fibres,  which  are  still  capable  of  a  good  degree  of  energetic  action. 
For  a  number  of  days  the  uterus  is  felt  to  be  as  large  as  a  child's  head 
above  the  pubis,  and  not  very  firm. 

Causes. 

The  most  common  cause  of  this  delay  is  inflammation  attacking  the 
substance  of  the  uterine  walls.  The  inflammation  may  be  acute,  and 
the  patient's  suffering  such  as  to  demand  attention,  or  so  slight  as  to 
pass  without  much  notice.  Cases  of  puerperal  metritis,  for  a  week  or 
ten  days  immediately  succeeding  delivery,  not  unfrequently  present 
this  enlarged  condition  of  the  organ. 

Another  cause  which  probably  operates  to  prevent  involution  is 
atony  of  the  uterine  muscular  fibres.  The  contractions  are  feeble, 
and  so  inefficient  as  to  delay  for  a  long  time,  and  render  very  slow, 
the  early  stages  of  involution.  Too  early  assumption  of  the  erect 
posture  and  undue  exercise  on  foot,  keeping  the  bloodvessels  of  the 
uterus  distended  unduly,  and  thus  overcoming  the  muscular  contrac- 
tion, are  not  unfrequently  the  causes  of  delayed  involution. 


SYMPTOMS PROGNOSIS — TREATMENT.  559 

Symptom,s. 

The  symptoms  of  delayed  involution,  separate  from  the  inflamma- 
tion, are  not  always  very  well  marked.  Weight,  heat,  and  aching  in 
the  back  are  the  most  frequent,  especially  if  inflammation  is  the  cause. 
There  is  always  great  danger,  however,  of  a  very  alarming  symptom 
while  this  state  of  the  uterus  exists,  and  that  is  flooding.  Where  the 
delayed  involution  is  dependent  on  atony  of  the  muscular  fibres,  hem- 
orrhage is  sure  to  take  place  if  the  patient  exerts  herself  considerably. 
As  the  first  indication  of  any  seriously  wrong  condition  of  the  uterus, 
the  patient  is  suddenly  seized  with  copious  hemorrhage,  which  sub- 
sides under  the  influence  of  rest,  cold,  and  astringents,  but  suddenly 
and  unexpectedly  recurs  without  adequate  cause.  When  suspected, 
the  diagnosis  is  not  difficult  by  an  examination  with  one  finger  of  the 
right  hand  per  vaginam,  while  with  the  left  hand  pressure  is  made 
above  the  pubis.  The  uterus,  thus  examined,  is  found  to  be  as  large 
as  immediately  after  labor  is  ended. 

The  soft,  uncertain  condition  of  the  uterine  globe  will  not  always 
enable  us  to  discover  it  by  placing  a  hand  upon  the  lower  part  of  the 
abdomen  alone,  but  by  including  the  organ  between  the  two  there  will 
be  no  danger  of  mistake.  If  the  organ  retains  sufficient  firmness  to 
be  easily  distinguished  above  the  pubis  by  the  single  hand,  there  will 
be  but  little  danger  of  hemorrhage.  The  local  distress  will  then  be 
the  only  indication  of  the  necessity  of  a  diagnostic  examination,  when 
the  greatly  enlarged  condition  will  be  easily  detected  by  the  examina- 
tion above  directed.  The  fingers  may  be  easily  made  to  enter  the 
mouth  of  the  organ  and  move  the  whole  mass,  while  the  hand  above 
will  easily  recognize  the  movement,  or  the  hand  above  may  be  made 
to  press  it  down  upon  the  fingers  below. 

Prognosis. 

There  is  imminent  danger  of  serious,  if  not  fatal,  hemorrhage.  I 
have  known  as  many  as  two  cases  of  sudden  fatality  from  flooding 
after  the  seventh  day  from  the  time  of  labor.  It  is  always  a  serious 
condition,  and  should  be  watched  diligently  and  treated  efficiently. 
Even  in  cases  where  the  delay  is  caused  by  acute  inflammation  great 
hemorrhage  may  take  place,  although  not  so  likely  as  when  caused  by 
muscular  atony  alone.  If  the  delay  is  for  a  very  considerable  length 
of  time,  the  involution  is  pretty  sure  not  to  be  completed,  but  the  uterus 
remains  in  a  state  of  subinvolution  for  an  indefinite  time.  Very  often 
the  causes  which  effect  delays  continue  to  act,  and  finally  produce 
subinvolution. 

Treatment. 

The  treatment  depends  upon  the  causing  conditions.  If  there  is 
inflammation  of  the  uterus  the  antiphlogistic  measures  necessary  to 


560      DISEASED    DEVIATIONS    OF    INVOLUTION   OF    THE    UTERUS, 

combat  it  are  demanded,  with  counter-irritation,  fomentations,  etc. 
Should  atony,  unattended  with  inflammation,  exist,  ergot  in  large 
doses  is  demanded  imperatively  until  ergotism  is  manifested. 

I  usually  give  3ss.  pulv.  secale  corn,  in  infusion,  every  half  hour 
until  there  are  contractions.  When  this  is  done  the  effect  of  the 
drug  may  so  subside  that  it  will  be  necessary  to  administer  it  again  in 
twelve  or  twenty-four  hours,  until  all  disposition  to  relax  has  passed 
away.  When  atony  and  the  inflammatory  condition  coexist,  which 
may  be  known  by  the  tenderness,  fever,  and  hemorrhage  occurring  to- 
gether, the  ergot  and  other  treatment  should  be  combined.  Hemor- 
rhage is  not  likely  to  come  on  until  after  the  inflammation  has  pretty 
well  subsided,  and  aids  usually  in  removing  the  last  of  it. 

I  subjoin  two  cases  as  representatives  of  the  two  conditions  of  the 
uterus,  and  the  mode  of  treating  them: 

Case  I.  This  case  was  furnished  me  by  Dr.  S.  Wickersham,  of  this 
city.  He  was  called  to  see  Mrs.  E.,  an  Irishwoman,  aged  twentj^-eight, 
in  her  fourth  labor.  May  7th,  1863,  4  o'clock  p.m.  She  had  been  in 
labor,  attended  by  a  midwife,  for  the  most  of  the  day.  At  1  o'clock 
A.M.  of  the  8th,  pains  had  entirely  ceased,  from  atony  or  exhaustion 
of  the  uterus.  Constitutional  symptoms  began  to  show  the  necessity 
for  relief  The  forceps  were  used,  and  the  child  was  delivered.  The 
placenta  was  delivered  in  due  time  without  difficulty,  and  the  uterus 
contracted  well.  Hemorrhage  not  more  than  usual.  The  pulse  was 
unusually  frequent  at  and  after  the  time  of  delivery.  The  labor  was 
followed  in  two  days  with  puerperal  fever,  in  which  the  uterus  and 
peritoneum  were  both  involved.  Up  to  the  20th  she  had  improved 
very  much,  so  as  to  be  considered  by  the  doctor  as  convalescent.  In 
the  early  part  of  the  day  sudden  and  violent  hemorrhage  prostrated 
the  patient  to  what  was  at  the  time  considered  a  moribund  condition 
but  by  active  stimulation  and  external  warmth  to  her  cold  extremi- 
ties she  rallied,  and  appeared  to  be  slowly  recovering.  At  6  o'clock 
P.M.  on  the  24th,  the  hemorrhage  returned  with  "terrible  violence," 
and  she  was  thought  again  to  be  dying.  Notwithstanding  the  most 
energetic  use  of  stimulants  she  could  hardly  rally  from  this  last 
attack.  On  the  26th,  in  consultation  with  Dr.  Wickersham,  I  found 
the  patient  so  prostrated  as  to  leave  but  little  hope  of  her  recovery. 
Suspecting  that  the  uterus  was  in  a  state  similar  to  what  is  found 
immediately  after  delivery,  I  insisted  upon  making  an  examination, 
which  was  resisted  by  the  patient  and  friends.  Through  the  kind 
perseverance  of  Dr.  Wickersham  I  was  permitted  to  do  so.  The 
uterus  was  so  flaccid  that  I  could  not  discover  it  above  the  pubis 
until  after  introducing  the  finger  into  the  vagina  and  moving  it  about, 
when  the  fundus  could  be  felt  as  high  as  the  umbilicus,  with  the 
regular  globular  form.  The  mouth  and  cervix  were  large  and  flabby, 
and  easily  admitted  two  fingers.     After  this  examination  the  indica- 


TREATMENT.  561 

tion  seemed  plain.  Large  closes  of  ergot  were  given  in  addition  to 
the  stimulating  and  supporting  treatment.  Hemorrhage  was  very 
slight  on  the  morning  of  the  27th.  She  continued  to  improve  slowly 
until  the  9th  of  June.  At  5  o'clock  a.m.  the  hemorrhage  returned, 
and  lasted  until  10  o'clock  a.m.,  but  in  so  moderate  a  degree  as  to 
produce  but  little  effect  upon  the  patient.  I  was  not  in  attendance 
after  the  first  consultation,  and  could  not  trace  the  steps  of  condensa- 
tion, but  after  the  9th  of  June  the  hemorrhage  did  not  recur. 

It  will  be  seen  that  on  the  twelfth  day  after  confinement  dangerous 
hemorrhage  took  place ;  that  it  again  returned  on  the  sixteenth  day 
after  delivery  to  a  very  alarming  extent ;  and  that  after  the  liberal 
use  of  ergot  the  hemorrhage  returned  but  slightly.  It  should  be 
noted,  also,  that  the  cessation  of  the  hemorrhage  was  sudden,  and 
probably  resulted  from  faintness,  and  that  it  returned  as  soon  as  the 
arterial  reaction  amounted  to  any  considerable  degree.  The  faint- 
ness, doubtless,  was  the  cause  of  stoppage  in  both  attacks  before  ergot 
was  given,  but  the  hemorrhage  was  effectually  checked  by  contrac- 
tions produced  by  the  ergot. 

Case  II.  Mrs.  E.  is  the  mother  of  nine  children.  She  is  thirty- 
three  years  of  age,  and  a  German  Jewess.  Of  robust,  almost  athletic 
make  and  habits,  she  always  enjoys  excellent  health.  In  the  last 
three  confinements  she  has  almost  lost  her  life  from  loss  of  blood, 
both  before  and  after  the  delivery  of  the  placenta.  I  attended  her  in 
the  eighth  labor,  the  last  before  this  one.  There  was  nothing  peculiar 
in  it  until  after  the  child  was  delivered,  the  labor  having  lasted  but 
about  four  hours.  The  pains  were  ordinarily  vigorous  and  propul- 
sive. The  liquor  amnii  was  not  evacuated  until  ten  minutes  before 
the  head  was  distending  the  labia.  After  the  child  was  expelled  the 
uterus  did  not  contract  thoroughly.  It  seemed  large  and  rather  soft. 
This  state  lasted  for  half  an  hour,  when  a  feeble  contraction  detached 
but  did  not  expel  the  placenta.  From  this  time  hemorrhage  became 
excessive.  I  waited  for  half  an  hour — using  friction,  kneading,  and 
pressure  over  the  uterus,  with  application  of  ice  to  the  vulva — for- 
contraction  of  the  uterus  and  expulsion  of  the  placenta,  but  although, 
there  were  occasional  pains,  they  were  so  feeble  as  to  produce  no 
effect  upon  the  hemorrhage.  About  this  time  the  ergot  I  had  sent  for 
arrived,  and  I  gave  immediately  3ss.  in  a  little  wine  and  water. 
Fearing  the  prostration  which  was  rapidly  coming  over  the  patient,  I 
introduced  my  hand  into  the  uterus,  grasped  the  placenta,  and  irri- 
tated the  organ  by  moving  the  whole  around  in  it.  This  brought  on 
contractions  enough  to  expel  my  hand  and  placenta,  and  deluge  the 
bed  with  coagula  and  fluid  blood.  Very  soon  the  ergot  began  to  act, 
and  the  hemorrhage  ceased.  I  give  this  description  of  her  eighth 
labor  to  show  her  predisposition  to  inertia  uterina.  As  the  ninth 
labor  approached,  I  determined  I  would  administer  the  ergot  as- soon 

36 


562  suBI^'V0LUTI0N  or  the  uterus. 

as  the  parts  were  well  dilated,  and  the  head  began  to  pass  the  os 
uteri.  I  was  sent  for  at  8  o'clock  p.m.,  June  30th,  1864,  to  attend  her. 
I  found  the  pains  active  and  the  os  uteri  fully  dilated,  and  the  mem- 
branes distending  the  labia.  I  at  once  gave  her  ergot  3ss.  in  infusion, 
making  her  swallow  the  ergot  as  well  as  the  water.  This  was  rej)eated 
in  half  an  hour.  By  this  time  ergotism  was  fairly  established.  In 
three-quarters  of  an  hour  from  the  time  I  arrived  the  child  was  born, 
and  in  a  few  minutes  the  placenta  was  expelled  from  the  uterus  into 
the  vagina  whence  it  was  removed.  No  hemorrhage  followed.  The 
uterus  was  well  contracted.  I  considered  her  condition  very  favor- 
able, and  at  the  end  of  another  hour  took  my  leave.  Her  condition 
for  the  first  forty-eight  hours  was  in  no  respect  unusual,  except  that 
the  lochial  discharge  was  rather  free.  From  this  time  I  saw  but  little 
of  her  until  the  10th  of  July.  I  returned  from  the  country  at  5  o'clock 
P.M.,  and  found  she  had  been  flooding  since  early  in  the  morning,  not 
very  greatly,  but  sufficient  to  begin  to  produce  faintness.  The  uterus 
could  be  felt  above  the  symphysis  pubis  as  large  as  a  child's  head, 
and  not  very  hard.  I  ordered  cold  to  the  jDubis,  and  twenty  droj^s  of 
aromatic  sul.  acid  in  some  water  every  four  hours,  expecting  soon  to 
have  the  hemorrhage  checked  ;  but  to  my  surj^rise,  at  8  o'clock  on  the 
11th,  the  hemorrhage  still  continued,  being  but  slightly  moderated  by 
the  means  used.  I  now  ordered  two  teaspoonfuls  of  vin.  ergoti  every 
half  hour  until  the  hemorrhage  ceased.  But  the  nurse  said  that  the 
"  second  dose  put  her  in  so  much  pain  and  caused  such  large  clots  of 
blood  to  come  from  her  that  she  dare  not  give  it  again."  The  hemor- 
rhage ceased  entirely  from  this  time  until  the  afternoon  of  the  13th, 
when  it  returned  with  considerable  violence.  The  ergot  was  again 
given,  and  from  this  time  forward  the  patient  had  a  favorable  con- 
valescence, and  is  now  in  the  enjoyment  of  good  health. 

Subinvolution  of  the  Uterus. 

To  understand  subinvolution  in  its  princijDal  bearings  it  will  be 
necessary  to  discuss  more  at  length  the  subject  of  involution  itself. 
I  think  that  involution  of  menstruation  plays  a  much  more  important 
part  in  the  structural  diseases  of  the  uterus  than  we  have  been  inclined 
to  attribute  to  it.  It  will  not  be  considered  irrelevant,  therefore,  to 
take  a  glance  at  the  subject,  as  involution  presents  itself  in  menstrua- 
tion as  well  as  in  pregnancy. 

In  the  healthy  uterus,  what  may  be  called  trophic  changes  are  con- 
stantly going  on,  from  the  beginning  of  menstruation  to  the  meno- 
pause. The  circulation  of  the  uterus  is  increased  in  quantity  from  the 
cessation  of  one  menstrual  crisis  to  the  beginning  of  the  next.  During 
the  days  of  the  flow  the  afflux  of  blood  subsides  to  the  lowest 
amount. 


SUBINVOLUTION    OF    THE    UTERUS.  563 

From  the  cessation  of  the  monthly  flow  there  is  an  increase  of  solid 
tissue  in  the  uterus  until  the  beginning  of  the  next  menstrual  flow, 
during  which  time  there  is  involution  or  an  elimination  of  solid  tissue, 
notably  the  mucous  membrane  of  the  cavity.  ' 

These  processes  of  afflux  of  blood  and  accretion  of  tissue  may  be, 
and  often  are,  prolonged,  and  pass  into  what  is  known  as  congestion 
of  the  uterus. 

When  this  round  of  monthly  changes  is  interrupted  by  pregnancy, 
processes  similar  in  character  on  a  much  larger  scale  are  accomplished. 
The  afflux  of  blood  and  increment  of  tissvie  do  not  attain  their  maxi- 
mum until  the  end  of  gestation.  The  contents  of  the  uterus  are  ex- 
pelled, and  then  begin  the  changes  called  involution,  the  object  of 
which  is  the  elimination  of  the  superfluous  circulation  and  solid 
tissues,  until  the  uterus  returns  to  its  menstrual  status. 

The  prolongation  or  arrest  of  this  is  subinvolution. 

Post  partum  involution  is  no  doubt  initiated,  if  it  is  not  completed, 
through  the  agency  of  muscular  contractions.  The  large  fibres  which 
have  been  strong  enough  to  expel  the  foetus,  placenta,  and  membranes, 
continue  to  contract,  and  in  doing  so  compress  the  vessels,  and  thus 
cut  off  at  once  a  large  quantity  of  the  blood  circulating  in  the  uterus. 
As  a  result  of  this  some  of  the  fibres  are  deficiently  supplied  with 
nutritive  elements,  and  undergo  fatty  degeneration.  The  granular 
fatty  material  is  absorbed  and  the  general  bulk  of  the  organ  dimin- 
ished. Further  contraction  is  thus  rendered  possible,  when  more 
fibres  disappear  in  the  same  way  until  the  process  of  involution  is 
finished.  The  length  of  time  required  is,  I  think,  much  longer  than 
is  generally  supposed,  seldom  in  one  month,  often  not  in  three  months, 
and  sometimes  morbid  causes  prevent  it  from  ever  being  accomplished. 
The  uterus  then  remains  more  vascular  and  bulky  than  normal,  or  is 
in  a  state  of  subinvolution. 

In  both  post-menstrual  and  post-partum  subinvolution  this  simple 
vascular  condition  does  not  continue  for  any  great  length  of  time. 
Hypersemia  is  often  a  mischievous  condition,  and  sooner  or  later 
causes  changes  in  the  organization  of  the  viscus  in  which  it  exists. 
In  subinvolution  there  is  at  first  hypersemia,  with  hypertrophy  of  the 
fibrous,  vascular,  and  nervous  tissues.  These  solid  portions  of  the 
organ  degenerate,  not  into  a  fatty  substance  that  may  be  absorbed, 
but  into  fibrous  tissue  of  a  low  organization. 

Either  as  the  eff'ect  of  exudation  from  the  capillaries,  or  the  slow 
absorption  of  the  more  vitalized  molecules  of  the  muscular  fibres,  or 
both,  there  comes  to  be  an  undue  amount  of  connective  tissue.  The 
transition  from  the  more  muscular  and  highly  vitalized  state  of  the 
uterus  to  this  one  of  induration  may  be  accomplished  in  a  few  months, 
or  it  may  require  the  lapse  of  years.  When  it  is  complete,  many  of 
the  symptoms  that  indicated  the  state  of  recent  subinvolution  are  re- 


564  SUBINVOLUTION    OF   THE    UTERUS. 

placed  by  others  of  a  different  kind ;  especially  do  the  bloody  dis- 
charges from  the  uterus  become  less  than  normal. 

Subinvolution  is  a  term,  then,  which  embraces  different  pathological 
conditions;  or,  perhaps,  it  would  be  expressing  the  facts  better  to 
say  that  several  distinct  pathological  conditions  of  the  uterus  result 
from  subinvolution.  This  last  statement  will  apply  equally  to  men- 
strual subinvolution  as  to  the  post-partum. 

We  ought  not  to  lose  sight  of  the  fact  that  all  the  physiological  and 
some  of  the  pathological  changes  occurring  in  the  uterus  are  to  a 
great  extent  coincidental  with,  if  not  the  consequences  of,  the  changes 
going  on  in  the  ovaries, — the  organs  that  dominate  the  whole  genital 
system. 

During  ovulation  the  menstrual  hypertrophy  takes  place ;  at  the 
time  of  the  discharge  of  the  ovum  menstrual  involution  occurs. 
During  the  development  of  the  ovum  in  the  uterus,  ovarian  hyper- 
trophy is  going  on ;  at  the  time  of  the  expulsion  of  the  ovum  the  pro- 
cesses of  involution  begin. 

It  is  quite  probable  that  after  the  ovum  is  inclosed  in  the  uterus 
and  gestation  established,  the  uterus  is  ijrompted  by  ovarian  influence 
to  the  enormous  physiological  and  anatomical  changes  which  go  for- 
ward in  it,  up  to  the  perfection  of  fetal  life,  and  afterward  govern  the 
processes  of  labor  and  involution.  It  is  certain  that  the  ovaries  do 
not  return  to  the  condition  in  which  they  were,  before  conception, 
until  pregnancy  has  terminated,  nor  in  fact  during  several  months  of 
lactation. 

While  the  generative  functions  of  the  ovaries  are  held  in  abeyance 
by  lactation, — or,  if  I  may  express  it  differently,  while  the  ovaries  are 
engaged  in  the  reflex  duties  of  sustaining  lactation, — they  do  not  re- 
turn to  their  former  condition.  According  to  my  observation,  involu- 
tion of  the  uterus,  ovaries,  and  vagina  is  not  complete  in  persons  who 
nurse  their  children  until  the  ordinary  term  of  lactation  has  elapsed. 
Looked  at  in  this  way  I  think  involution  will  present  different  feat- 
ures than  when  viewed  from  a  more  circumscribed  standpoint.  We 
will  attach  more  importance  to  the  influence  of  the  nervous  system, 
exerted  through  the  ovaries. 

The  term  and  process  of  involution  extend  to  the  changes  observed 
in  all  the  genital  organs,  the  lacteal  glands,  the  ovaries,  uterus,  vagina. 
Fallopian  tubes,  uterine  ligaments,  and  perineum.  How  much  more 
susceptible  to  the  effects  of  morbid  causes,  therefore,  must  be  all  the 
contents  of  the  pelvis  in  the  hyperaemic,  hypersesthetic,  and  hyper- 
trophic conditions  during  the  time  involution  is  going  on,  and  how 
readily  the  affections  of  one  pelvic  organ  will  influence  the  condition 
of  all  the  others. 

The  genital  organs  constitute  a  separate  and,  in  some  respects,  inde- 
pendent physiological  system,  governed  by  special  nervous  centres,  all 


CAUSES — FREQUENCY   OF    ITS    OCCURRENCE.  565 

bound  together  and  dominated  by  the  ovaries,  under  all  the  physio- 
logical changes  accompanying  pregnancy,  labor,  and  involution. 

Causes. 

Any  morbid  causes  that  prolong  the  processes  of  involution  may 
arrest  the  process  entirely.  The  character  of  the  labor  may  have  this 
effect.  If  it  has  been  tedious  enough  to  produce  great  nervous  ex- 
haustion, the  uterine  fibres  will  be  powerless  to  conduct  the  changes 
necessary  to  a  speedy  and  perfect  involution. 

If  the  cervix  is  lacerated  or  badly  contused,  the  consequent  inflam- 
matory reaction  interrupts  involution  for  a  greater  or  less  length  of 
time,  or  perhaps  for  all  time. 

Inflammation  of  the  body  of  the  uterus  resulting  from  severe  labor 
or  exposure  may  do  the  same  thing.  General  and  special  causes  not 
dependent  upon  labor  often  act  so  as  to  bar  the  completion  of  in- 
volution. Some  of  these  causes  are  general  debility,  an  impoverished 
condition  of  the  blood,  lack  of  nervous  energy,  a  want  of  the  jjowers 
of  endurance,  cold  acting  through  the  nervous  system  u[)on  the  circu- 
lation of  the  uterus  post-partum  or  during  menstrual  congestion,  the 
excitement  of  anger,  fevers,  or  the  depression  of  fear,  etc. 

Special  causes  operate  through  the  genital  nervous  centres  upon 
the  uterus  directly,  as  venereal  excitement  from  unnatural  lascivious 
practices,  coition  during  or  just  before  menstruation  and  within 
the  month  after  labor,  libidinous  literature,  and  exciting  exhibi- 
tions. 

Diseases  in  the  surrounding  organs,  by  keeping  up  nervous  and 
vascular  excitement,  ulceration,  fissure,  and  hemorrhoids  of  the 
rectum,  specific  vaginal  inflammation,  laceration  of  the  perineum, 
urethral  and  vesical  inflammation,  displacements  of  the  uterus,  etc., 
all  tend  to  produce  this  effect. 

Frequency  of  its  Occurrence. 

Without  exaggerating  the  importance  of  subinvolution,  I  believe  it 
would  be  correct  to  say,  that  more  of  the  chronic  congestions  of  the 
uterus  originate  in  puerperal  and  menstrual  subinvolution  as  here 
explained  than  in  any  other  one  condition. 

By  taking  the  puerperal  and  menstrual  involution  as  a  fundamental 
and  almost  constantly  present  condition  of  the  pelvic  organs  for  a 
basis,  I  think  we  can  better  explain  the  mode  of  operation  of  exciting- 
causes  in  producing  chronic  diseases  than  by  any  other  hypothetical 
method.  Certain  it  is,  that  there  is  no  other  organ  in  the  body  so 
prone  to  lesions  of  circulation  and  their  consequences  as  the  uterus, 
and  that  the  reason  why  this  is  the  case  must  reside  in  the  anatomy 
and  functions  of  the  orean. 


566  suBusrvoLUTiox  of  the  uterus. 

It  is  an  organ,  the  very  nature  of  whose  condition  is  one  of  unceas- 
ing fluctuation  of  vascularity  and  nervous  suscej^tibility. 

Symptoms  and  Diagnosis. 

The  general  symptoms  of  subinvolution  are  in  no  respects  distinc- 
tive. All  the  reflex  symptoms  sjDoken  of  as  uterine  symptoms,  or 
symptoms  of  uterine  disease,  may  exist  in  jDatients  the  subjects  of  this 
condition;  neither  do  the  local  sj^mptoms  guide  us  with  certainty  to 
a  correct  diagnosis.  In  the  earlier  months  of  subinvolution,  in  fact 
for  an  indefinite  term,  metrorrhagia  is  a  frequent  sjmiptom,  and  in 
some  instances  continues  as  long  as  the  disease  lasts.  It  represents 
what  may  be  termed  the  vascular  stage  of  subinvolution.  In  a  great 
many  cases  of  subinvolution  after  a  certain  time,  which  also  is  very 
indefinite,  the  bloody  discharge  from  the  uterus  becomes  less  copious, 
and  occasionally  entirely  ceases.  The  diminution  of  the  flow  indi- 
cates the  supervention  of  the  fibrino-plastic  stage,  or  a  condition  in 
which  the  vascularity  of  the  uterus  is  diminished  while  the  solid 
tissue  is  increased.  Leucorrhoea  is  generally  present  or  absent  under 
the  same  conditions  that  govern  the  flow  of  blood. 

Diagnosis. 

The  diagnosis  must  be  made  up  from  the  history  and  physical 
examinations.  If  the  sufferings  of  the  patient  date  from  an  abortion, 
or  labor  at  full  term,  and  in  addition  to  the  general  and  local  symp- 
toms of  uterine  disease  there  is  or  has  been  for  months  too  copious  or 
too  frequent  menstrual  discharges,  or  hemorrhages  intervening  be- 
tween the  regular  periods,  the  presumption  is  that  there  is  subinvolu- 
tion, or  at  least  that  the  symptoms  were  at  first  those  of  that  condi- 
tion. One  of  the  most  constant  appreciable  conditions  of  subinvolution 
is  the  large  size  of  the  uterus.  This  may  be  ascertained  by  bimanual 
examination  and  the  introduction  of  the  sound. 

When  the  uterus  is  lifted  up  by  the  fingers  in  the  vagina,  the  fundus 
will  be  more  easily  felt  by  the  hand  above,  and  the  sound  will  pass 
farther  beyond  the  normal  dejDth  into  the  cavity  than  when  the  organ 
is  of  a  normal  size. 

The  shape  of  the  uterus  is  generally  still  that  of  the  post-partum 
organ.  It  is  proportionated  thicker  through  its  antero-posterior 
diameter.  The  enlargement,  therefore,  is  difi'erent  from  enlargements 
from  other  conditions. 

The  shape  is  often  modified  by  retroflexions  and  lacerations  of  the 
cervix.  When  retroflexed  Avithout  laceration,  the  fundus  and  body 
are  much  larger  proportionate!}^  as  compared  with  the  cervix.  When 
the  cervix  is  badly  lacerated,  it  is  enlarged.  The  appearances  in  this 
resj^ect  are  sometimes  deceptive  when  the  labia  are  widely  separated. 


PROGNOSIS TEE  ATMENT.  567 

When  examined  through  the  speculum  the  color  is  deeper  than 
natural,  the  mouth  patulous,  the  cervix  large  and  often  ulcerated. 
Generally,  also,  there  is  copious  albuminoid  mucus  hanging  from  the 
OS  uteri,  sometimes  of  an  amber  color,  from  the  admixture  of  pus- 
corpuscles.  When  the  cervix  is  lacerated,  the  mucous  membrane  of 
the  cervical  cavity  is  exposed,  and  presents  a  papillary  or  fungoid 
appearance. 

These  are  the  appearances  in  the  vascular  stage  of  subinvolution. 
After  this  has  passed,  and  the  fibrino-plastic  change  has  taken  place, 
the  cervix  and  body  will  feel  hard  to  the  touch  ;  sometimes  the  indu- 
ration in  such  cases  is  very  marked  indeed.  While  the  induration  is 
generally  uniform  with  respect  to  the  cervical  circle,  and  extends  en- 
tirely around,  at  other  times  it  is  confined  to  one  of  the  lips.  Then 
the  color  is  often  not  increased,  and  the  surface  is  smooth  and  covered 
with  cicatricial  tissue  instead  of  granulations  or  fungoid  bodies. 

Prognosis. 

During  the  vascular  stage  of  subinvolution,  and  while  the  hyper- 
trophied  fibres  of  the  uterus  retain  their  muscular  character,  we  may 
hope  to  succeed  in  restoring  the  normal  condition  of  the  organ.  We 
must  remember,  however,  that  metrorrhagia,  indicating  great  vascu- 
larity of  the  uterus,  is  no  evidence  that  the  fibres  are  not  greatly 
X3hanged  or  replaced  by  non-contractile  tissue,  and  consequently  the 
prognosis  should  be  guarded.  The  longer  the  time  the  case  has 
lasted,  the  greater  the  probabilities  are  that  the  fibres  are  replaced  by 
connective  tissue. 

After  this  vascular  and  hypertrophic  condition  of  the  muscular 
fibres  have  passed  away,  and  there  has  been  extensive  fibrino-plastic 
deposit  in  the  walls  of  the  uterus,  the  probabilities  of  a  cure  are  very 
remote.  The  uterus  is  then  hard,  inelastic,  its  tissues  permeated  by 
few  vessels,  and  the  nerves  diminished,  if  not  entirely  absent. 

Treatment. 

The  preventive  treatment  should  begin  during  pregnancy.  Every 
means  necessary  to  place  the  patient  in  good  health,  both  generally 
and  locally,  must  be  resorted  to, — exercise  in  the  open  air  on  foot,. 
if  at  all  practicable,  and  domestic  employment  or  jesercise  of  like- 
character. 

The  habits  of  the  patient  should  be  regulated  with  a  view  to;  the 
development  of  the  muscles  of  the  entire  body,  while  her  diet  shcoQ-ld' 
be  abundant  in  quantity  and  of  the  most  nutritious  quality. 

It  is  not  my  purpose  at  this  time  to  do  more  than  to  call  the  attenr- 
tion  of  the  obstetrician  to  the  subject  of  preparing  patients  for  the 
great  task  of  passing  safely  through  labor.     During  labor  everything; 


568  SUBINVOLUTION   OF   THE    UTEEUS. 

should  be  conducted  with  the  view  of  preserving  the  integrity  of  all 
the  soft  parts,  because,  as  before  intimated,  damage  to  any  of  the 
parts  concerned  in  labor  is  pretty  sure  to  be  followed  by  subinvolu- 
tion. 

The  more  physiological  a  labor  is,  and  the  more  skilfully  conducted, 
the  less  the  tendency  to  subinvolution. 

After  labor  complete  contraction  should  be  brought  about,  and 
maintained,  not  by  mechanical  irritation,  but,  if  need  be,  by  the  use 
of  ergot  and  vaginal  injections  of  hot  water.  These  latter  will  stimu- 
late the  j)elvic  nerves  and  prompt  the  uterus  to  contraction,  and  by 
their  cleansing  effects  promote  the  repair  of  every  damage  that  the 
soft  parts  may  have  sustained.  Above  all  things,  a  sufficient  amount 
of  absolute  rest  must  be  enjoined  to  insure  recovery  of  the  viscera. 

The  most  assiduous  attention  should  be  especially  given  to  control 
all  inflammations  that  follow  labor. 

From  the  immense  number  of  gynecological  cases  traceable  to  labor, 
it  is  to  be  feared  that  some  of  the  modern  innovations  in  the  practice 
of  midwifery  are  not  improvements. 

More  attention  and  care  in  conducting  patients  through  cases  of 
abortion  and  jjremature  labor  should  be  practiced  than  is  usually 
done. 

Abortion  is  looked  upon  by  the  patients  themselves  as  a  small  mat- 
ter, and  it  is  very  difficult  to  induce  them  to  give  the  necessary  time 
and  care  to  themselves.  Physicians  know  that  it  is  a  more  disastrous 
process  than  labor  at  full  term,  and  they  will  do  service,  therefore,  by 
enforcing  proper  measures,  whenever  it  is  practicable,  to  insure  good 
recovery  from  it. 

After  the  patient  has  passed  from  the  hands  of  the  accoucheur  to 
those  of  the  gynecologist  the  treatment  of  subinvolution  will  be  gov- 
erned by  the  conditions  in  each  case.  Until  the  muscular  fibres  have 
lost  their  power  of  contraction,  ergot,  strychnia,  quinine,  and  iron, 
with  good,  nutritious  diet  and  exercise  in  the  open  air,  will  be  the  gen- 
eral remedies  most  efficacious. 

Ergot,  given  in  moderate  doses,  perseveringly  administered,  is  a  very 
powerful  means  of  supiolementing  the  natural  contractions.  It  is  not 
applicable  to  cases,  however,  where  there  is  inflammatory  excitement 
in  the  uterine  substances,  and  should  be  withheld  until,  by  alteratives, 
counter-irritants,  and  rest,  that  condition  is  removed.  When  this 
inflammatory  condition  is  not  present  the  ergot  and  tonics,  judiciously 
administered,  will  co-operate  well  in  the  accomplishment  of  the  gen- 
eral result.  However,  gynecologists  do  not  often  see  these  cases  until 
the  contractility  of  the  fibres  has  been  very  much  impaired,  if  not 
entirely  lost.  In  most  cases,  even  thus  late,  the  ergot  and  tonics  will 
have  some  good  effect. 

In  chronic  cases  the  local  treatment  is  of  prime  importance ;  and 


TREATMENT.  569 

the  first  thing  to  be  thought  of  is  the  removal  of  any  cause  of  increased 
vascularity  that  may  be  found  associated  with  it.  If  there  is  lacera- 
tion of  the  cervix  or  perineum  it  should  receive  attention.  If  there  is 
misplacement  it  must  be  corrected,  so  that  the  outgoing  circulation 
may  be  as  free  as  possible.  When  these  conditions  are  corrected  we 
may  begin,  a  system  of  local  treatment  that  will  remove  the  congestion, 
and  cause  the  absorption  of  the  fibrino-plastic  deposits.  The  use  of 
glycerin  tampons  and  hot-water  injections  will  be  found  applicable 
and  beneficial  in  most  cases.  The  glycerin  cotton  should  be  applied 
about  every  second  or  third  day,  and  allowed  to  remain  in  the  vagina 
from  twenty-four  to  forty-eight  hours.  It  should  support  the  uterus 
so  as  to  relieve  the  tender  or  irritated  pelvic  tissues  of  all  strain. 

During  this  time  the  capillary  bloodvessels  will  be  depleted  by  the 
loss  of  a  part  of  the  serous  portion  of  the  blood  they  contain,  and  ex- 
osmosis  from  the  intervascular  spaces  will  also  be  excited  in  such  a 
manner  as  to  empty  them  of  their  contents.  This  leaves  the  part  with 
which  the  glycerin  comes  in  contact  white,  shrivelled,  and  lessened  in 
bulk,  ^.  e.,  depleted.  This  is  not  all  the  good  efi"ect  produced  by  the 
glycerin  applied  to  the  cervix  of  the  uterus,  for  the  frequent  removal 
of  the  serum  from  the  intervascular  spaces,  which,  of  course,  is  replaced 
by  a  fresh  supply  from  the  vessels,  is  a  very  efficient  means  of  dissolv- 
ing out  the  fibrino-plastic  material.  It  is,  in  fact,  a  kind  of  washing- 
out  of  the  tissue  with  serum  derived  from  the  minute  bloodvessels ;  it 
acts,  therefore,  both  as  a  depletent  and  a  solvent. 

Large  hot-water  injections  constitute  another  valuable  means  of 
overcoming  hypersemia,  and  causing  absorption  of  solid  deposits. 

But  there  is  another  class  of  local  remedies  that  is  more  serviceable 
than  these,  and  that  is  local  stimulants  applied  directly  to  the  mucous 
membrane,  such  as  iodine,  carbolic  acid,  tincture  of  iron,  acid  nitrate 
of  mercury,  and  many  others  that  I  might  mention.  In  the  teachings 
of  twenty-five  years  ago  the  application  of  these  remedies  to  the  mu- 
cous membrane  was  supposed  to  exert  only  a  very  limited  influence 
at  the  point  to  which  they  were  applied,  and  we  thought  in  applying 
nitrate  of  silver  to  an  abraded  or  ulcerated  surface  the  only  effect  it 
had  was  to  heal  up  the  abraded  patch.  Now  we  know  that  this  is  a 
very  small  part  of  the  effect  of  these  local  applications.  The  vasomotor 
nerve  supply  of  the  whole  uterus  is  so  intimately  connected  that  it  may 
be  considered  a  unit,  and  no  part  of  it  can  be  stimulated  without  aftect- 
ing  the  whole.  Applications  made  to  the  cervix  of  sufficient  strength 
to  stimulate  its  circulation  to  greater  activity  affect  every  fibre  and 
capillary  in  the  organ  in  a  similar  manner.  When,  therefore,  there  is 
chronic  engorgement  of  the  uterus,  the  very  best  way  to  get  rid  of  it  is 
to  stimulate  the  circulation  by  local  applications  to  the  cervix.  This 
same  principle  may  be  turned  to  great  advantage  by  stimulating  its 


570  HYPERIN  VOLUTION. 

internal  mucous  membrane,  and  one  of  the  best  wa5's  to  do  this  is  to 
scrape  the  cavity  of  the  uterus  with  a  dull  wire  curette. 

This  instrument  may  be  introduced  in  most  instances  without  diffi- 
culty, and  passed  slowly  but  firmly  over  the  whole  surface.  In  some 
instances,  where  the  mucous  membrane  is  soft,  small  pieces  may  be 
brought  out  by  the  instrument,  but  generally  this  is  not  the  case. 

When  pieces  of  the  mucous  membrane  are  thus  removed  it  would 
be  too  mechanical  an  explanation  to  say  that  the  patient  is  cured  be- 
cause the  uterus  has  been  partly  or  wholly  divested  of  its  diseased 
membrane.  It  is  the  excito-motor  influence  exerted  on  the  nerves, 
and  the  consequent  effect  upon  the  whole  circulation  of  the  organ, 
that  is  the  result  of  its  use. 

It  is  not  merely  to  the  hemorrhagic  condition  of  subinvolution,  but 
to  the  hypertrophic  condition  also,  that  the  curette  is  applicable. 

Dilatation  with  compressed  sponge  has  often  accomplished  good  in 
the  same  kind  of  cases  as  those  to  which  the  curette  is  adapted,  but  it 
is  a  much  more  hazardous  measure,  and  should  only  be  resorted  to 
when  the  other  means  fail. 

Hyperinvolution 

Is  the  state  of  the  organ  in  which  the  involution  has  proceeded  to 
such  a  degree  as  to  condense  the  tissues  beyond  their  ordinary  density. 
The  condensation  thus  accomplished  renders  it  less  vascular  and  erec- 
tile, and  the  fibrous  structure  is  paler  and  harder  than  natural.  As 
the  result  of  this  condensation  and  diminution  in  the  quantity  of  the 
circulation,  the  uterus  as  a  whole  is  smaller  and  lighter  than  common. 
The  degree  to  which  hyperinvolution  may  be  carried  varies  greatly ; 
sometimes  it  is  so  slight  as  to  require  great  care  to  distinguish  it,  at 
another  the  uterus  is  reduced  to  half  its  ordinary  weight  and  di- 
mensions. 

Causes. 

Inflammation  seems  here  to  be  more  concerned  in  the  production 
of  hyperinvolution  than  any  other  morbid  process.  From  examina- 
tions during  the  progressive  steps  of  morbid  states  of  involution,  I 
am  inclined  to  think  that  in  cases  where  inflammation  of  the  mucous 
structures  exists  exclusively,  or  where  inflammation  of  the  mucous 
membrane  preponderates,  the  involution  is  arrested,  and  hence  we 
have  subinvolution ;  but  when  the  inflammation  is  mostly  confined 
to  the  submucous  tissue  it  proceeds  to  hyjierin volution. 

Symptoms. 

The  condensation  of  the  tissue  and  reduction  of  the  vascularity  of 
the  organ  always  diminish  the  menstrual  flow ;  and  hence  we  have  de- 
creased menstruation  in  a  moderate  degree,  and  obstinate  amenorrhoea 


DIAGNOSIS.  571 

in  the  more  extreme  condition.  The  symptoms  attendant  upon  hyper- 
involution  are  very  similar  to  those  enumerated  in  the  description  of 
chronic  inflammation.  They  are  sometimes  very  distressing,  rendering 
the  patient  thoroughly  miserable  for  many  years.  The  worst  cases  of 
this  form  of  diseased  involution  I  have  met  with  have  been  traced  to 
inflammation  resulting  from  abortions ;  but  it  likewise  takes  place  as 
the  efi'ect  of  inflammation  after  ordinary  or  full  term  parturition. 

Diagnosis. 

The  diagnosis  is  easy  with  the  aid  of  the  uterine  sound.  This  in- 
strument will  not  enter  the  uterus  as  far  as  it  does  into  a  healthy  organ. 
The  uterus  is  lighter  and  more  easily  moved,  also,  by  the  finger  intro- 
duced into  the  vagina. 

One  of  the  almost  invariable  effects  of  hyperinvolution  is  sterility. 
I  have  met  with  a  number  of  cases  of  sterility  occurring  soon  after 
marriage,  on  account  of  abortion,  in  the  first  three  or  four  months, 
being  followed  by  inflammation  and  hyperinvolution,  the  patient  ever 
afterwards  remaining  sterile. 

The  successful  treatment  of  these  cases  requires  a  great  deal  of 
patience  and  well-adapted  measures.  If  the  change  in  the  condition 
of  the  uterus  is  slight  we  may  sometimes  succeed  by  introducing  a 
bougie  of  slippery-elm  bark,  large  enough  to  distend  the  cavity  of  the 
-cervix  as  much  as  practicable,  three  or  four  days  before  the  expected 
menstrual  discharge.  This  seldom  fails  to  increase  the  discharge,  and 
if  used  perseveringly  for  several  months  will  sometimes  cure  the  case. 
The  bougie  should  be  cut  out  of  the  bark  so  as  to  be  about  an  inch 
and  three-quarters  in  length,  for  cases  of  moderate  contraction,  and 
secured  by  a  thread  before  introducing  it.  It  should  be  allowed  to 
remain  until  the  discharge  begins,  and  then  removed.  If,  however, 
it  is  of  long  standing,  and  the  diminution  in  size  very  considerable, 
we  will  be  under  the  necessity  of  using  the  stem-pessary  recommended 
by  Professor  Simpson.  It  may  be  made  of  zinc  and  copper,  in  order 
to  add  the  influence  of  galvanism. 


CHAPTER    XXXY. 

CANCER  OF  THE  UTERUS. 

"Those  growths  maybe  termed  cancerous  which  destroy  the  natural 
structure  of  all  the  tissues,  which  are  constitutional  from  their  very 
commencement,  or  become  so  in  the  natural  process  of  their  de- 
velopment, and  which,  when  once  they  have  infected  the  constitu- 
tion, if  extirpated,  invaria,bly  return,  and  conduct  the  person  who  is 
affected  by  them  to  inevitable  destruction."  (Miller,  as  quoted  by 
West.) 

This  general  definition  of  cancer  will  include  all  its  varieties,  which 
are  usually  divided  into  four :  1st,  medullary  ;  2dly,  epithelial ;  3dly, 
colloid ;  4th]y,  scirrhus.  I  have  mentioned  these  varieties  in  the 
order  of  frequency  in  which  they  usually  occur  in  the  uterine  tissues. 
I  have  not  seen  either  a  case  of  colloid  or  scirrhus  in  the  uterus. 
There  can  be  little  doubt,  however,  that  both  are  met  with.  The 
medullary  variety  is  by  far  the  most  common  form  with  w^hich  this 
organ  is  affected,  the  epithelial  being  also  quite  common.  Cancer  of 
the  uterus  is  of  very  frequent  occurrence,  and  the  deaths  from  it,  com- 
pared to  death  from  the  same  disease  occurring  elsewhere  in  women, 
predominate  over  all  other  localities.  It  attacks  the  cervical  portion 
of  the  uterus  more  frequently  than  all  other  parts  of  the  organ,  yet  it 
begins  in  every  other  portion, — in  the  fundus,  body,  or  cavities  of  the 
body  or  cervix.  In  some  rare  instances  it  runs  its  course  to  fatal  re- 
sults without  involving  all  these  parts.  When  it  begins  in  the  cervix, 
it  usually,  either  gradually  or  suddenly,  passes  upward  to  the  fundus ; 
or  if  beginning  in  the  fundus  or  body,  it  creeps  downward  to  the  os 
tincse.  I  have  seen  two  instances  where  the  lower  portion  of  the  cer- 
vix was  but  slightly,  if  at  all  changed,  while  all  the  other  parts  of  the 
organ  were  infiltrated  by  cancerous  deposit.  The  material  of  cancer, 
particularly  the  medullary,  is  deposited  in  the  tissues,  supplanting 
them  more  or  less  perfectly. 

The  tissue  most  commonly  attacked  by  all  the  varieties  except  the 
epithelial  is  the  connective  tissue.  The  parts  attacked  are  thickened 
and  indurated,  the  thickening  and  induration  being  very  irregular  in 
shape  and  size.  If  one  of  the  lips  of  the  os  uteri  is  hardened  from 
cancerous  deposit,  the  elevated  points  are  sharp  and  angular,  and  the 
hardened  parts  terminate  abruptly,  and  in  a  manner  unlike  the  in- 
duration from  any  other  cause.  The  hardening  from  inflammatory 
fibrinous  deposit  is  more  globular  than  angular,  and  less  abrupt  in 
its  termination  in  the  sound  parts.     If  the  cancerous  deposit  is  in  the 


CANCER  OF  THE  UTERUS.  573 

body  or  side,  or  any  part  of  the  wall,  it  is  enlarged  into  an  irregular 
shape,  and  there  are  pits  and  points  in  many  places. 

The  infiltration  and  induration  increase  for  an  uncertain  length  of 
time,  until,  perhaps,  the  cancerous  deposit  so  far  displaces  and  re- 
places the  ordinary  tissues  that  the  nutrition  of  the  parts  is  disturbed 
by  the  destruction  of  the  bloodvessels,  and  sloughing  takes  place  over 
a  small  or  large  space,  but  always  over  an  irregular  space,  thus  leav- 
ing a  greater  or  less  chasm.  This  is  ulceration, — cancerous  ulcera- 
tion. The  absorbents  do  not  remove  the  parts,  and  thus  cause  ulcera- 
tion, but  there  is  sloughing  and  denudation  by  death  of  many  minute 
parts,  the  absorbents  having  but  little  to  do  in  the  process.  The 
sloughing  causes  the  smell  and  putrilaginous  character  of  the  dis- 
charges. This  process  widens  and  deepens  the  chasm,  sometimes 
quite  rapidly,  at  others  very  slowly.  In  the  case  of  the  medullary 
variety,  after  induration  and  enlargement  have  advanced  to  a  con- 
siderable extent  in  the  uterus,  the  nutrition  of  the  neighboring  organs 
and  tissues  is  disturbed,  and  the  deposit  is  infiltrated  into  all  the  sur- 
rounding parts, — the  bladder,  the  rectum,  the  areolar  tissue  by  the 
side  of  the  uterus,  the  peritoneum,  in  fact,  into  everything  in  the 
neighborhood.  This  general  deposit  is  not  limited  by  the  coverings 
or  divisions  of  the  parts,  but  all  become  united,  so  that  all  the  pelvic 
tissues  become  one  agglomerated  mass  of  cancer ;  or,  if  it  take  one 
direction  more  than  another,  the  bladder  and  uterus  may  be  glued 
together,  or  the  rectum  may  be  bound  thus  to  the  uterus.  This  dis- 
position of  the  deposit  very  soon  becomes  sufficient  to  fix  the  uterus 
immovably  in  its  place. 

After  the  ulcerative  process  has  fairly  begun,  it  advances  more  or 
less  rapidly,  until  much  of  the  surrounding  parts  is  destroyed ;  the 
bladder  and  uterus  become  one  continuous  cavity,  and  sooner  or  later 
the  rectum  also  is  laid  open,  and  then  the  pelvic  viscera  are  involved 
in  one  confused  excavation,  from  which  the  putrilage  of  cancerous 
degeneration  is  poured  out,  commingled  with  urine,  fseces,  and  blood. 

There  is  quite,  a  constant  proportion  between  the  rapidity  of  the 
destructive  progress  of  cancer  and  the  age  of  the  patient.  It  is  slower 
in  the  aged,  and  destroys  the  young  patient  most  readily.  Of  three 
cases  under  observation,  in  which  cancerous  deposit  began  in  the  body 
or  fundus  of  the  uterus  instead  of  the  neck,  two  were  in  patients  be- 
yond the  climacteric  period,  one  being  sixty-four  years  of  age  and  the 
other  fifty-seven  when  the  symptoms  first  attracted  their  attention. 
The  other  patient  was  forty-three.  In  this  last  patient,  simultane- 
ously with  the  evidence  of  deposit  in  the  body  of  the  uterus,  signs  of 
it  appeared  in  the  bladder,  vagina,  and  clitoris,  the  duodenum,  and 
in  the  pyloric  orifice  of  the  stomach.  I  always  look  for  a  more  rapid 
degeneration  of  the  tissues  invaded  by  cancer  in  comparatively  young 
patients. 


574  CANCEE  OF  THE  UTERUS. 

Synijotoms. 

Discharges,  pain,  and  fetor  are  the  symptoms  that  usually  attract 
our  attention  in  cases  of  cancer  of  the  uterus.  When  a  patient  com- 
plains of  any  of  these,  however,  the  case  is  generally  an  advanced 
one.  Pain,  perhaps,  is  the  symptom  first  experienced,  and  is  caused 
earlier  than  any  other.  Unfortunately,  pain  is  so  common  to  women 
— they  suffer  so  often  in  the  regions  of  the  uterus  and  hips — that  this 
symptom  is  not  heeded  by  them  until  some  other  symptom  makes  its 
appearance.  The  pain  is  not  generally  intense  nor  troublesome  until 
after  the  disease  is  recognized.  Nor  is  it  peculiar.  It  is  described 
as  lancinating,  darting,  twinging, — and  very  correctly,  too, — but  there 
is  often  no  pain  of  this  kind  during  the  whole  course  of  uterine 
cancer. 

The  discharges  in  cancer  are  of  three  kinds,  and  the  mixture  of 
them  in  different  proportions.  They  are:  1st,  blood;  2d,  limpid 
serum ;  3d,  sloughs,  generally  minute.  The  first  two  are  not  offen- 
sive to  the  smell  when  pure  or  mixed  together,  as  they  often  are,  and 
they  only  become  so  by  being  mingled  with  the  last,  by  dissolving  or 
holding  in  suspension  or  being  merely  mixed  with  greater  or  less 
pieces  of  dead  tissue.  In  the  earlier  stages  of  cancer  blood  or  serum 
may  be,  and  generally  is,  effused,  while  the  latter  is  reserved  to  the 
open  or  ulcerated  stage.  In  this  open  or  ulcerated  stage  all  three 
kinds  of  discharges  are  almost  always  mixed  together.  In  women 
who  are  still  menstruating,  the  discharge  first  experienced  is  of  blood. 
There  is,  at  first,  an  increase  in  the  amount  of  menstrual  discharge ;  a 
little  later,  and  blood  is  lost  between  the  times  of  menstruation.  The 
blood  thus  lost  is  derived  from  the  same  source  as  the  menstrual 
blood, — the  vessels  of  the  mucous  membrane  of  the  corpus  uteri. 
Later,  when  hemorrhage  is  so  constant  and  attended  with  fetor,  it  is 
effused  from  eroded  vessels  upon  the  ulcerated  surface. 

The  blood  in  the  former  case  is  produced  as  the  result  of  constant 
turgescence ;  in  the  latter,  on  account  of  the  disintegration  of  tissue. 
Limpid,  unoffensive  serum  is  almost  always  observed  in  the  cases  of 
old  women,  after  the  menstrual  period  of  life  has  passed,  and  gener- 
ally coming  from  the  os  uteri,  which  may  be  for  a  long  time  un- 
changed, indicating  that  it  comes  from  some  distance  up  in  the  organ. 
In  fact,  if  the  same  serum  was  effused  from  the  surface  of  the  vaginal 
portion  of  the  cervix  it  would  most  likely  be  mixed  with  blood,  be- 
cause the  parts  producing  it  would  not  be  sufficiently  protected  to 
insure  the  integrity  of  such  frail  tissue.  In  two  remarkable  instances 
the  copious  discharge  of  this  limpid  serum  was,  for  many  months,  the 
only  sign  of  disease  presented  by  the  patients.  One  of  my  patients, 
sixty-one  years  old,  had  been  under  the  necessity  of  wearing  napkins 
for  six  or  more  months  before  calling  my  attention  to  her  condition. 


SYMPTOMS.  575 

The  discharge  was  so  copious  when  I  saw  her  for  the  first  time  that  I 
collected  about  two  drachms  from  the  speculum  in  ten  minutes. 
When  examined  it  was  found  to  resemble  distilled  water  in  appear- 
ance, it  was  so  clear  and  colorless.  There  was  no  smell  nor  other 
offensive  quality  to  it.  When  examined  b}^  the  microscoj)e  no  solid 
substances  were  found,  except  a  very  few  natural  epithelial  scales. 
In  a  very  gradual  manner  this  transparent  liquid  became  colored  with 
blood.  It  was  sometimes  clear  and  sometimes  bloody  for  several 
months  before  becoming  fetid,  and  only  for  a  few  weeks  before  the 
patient  died  was  it  constantly  bloody  and  fetid.  The  cervix  uteri  in 
this  case  was  not  attacked  at  all,  and  the  mouth  and  lips  of  the  neck 
were  natural.  The  body  of  the  uterus,  as  high  as  the  fundus,  was 
enlarged  more  than  double  its  natural  size,  indurated,  and  nodulated  ; 
and,  when  examined  after  death,  the  walls  presented  the  peculiar 
friable  hardness  of  medullary  cancer,  but  there  was  no  excrescence  in 
the  cavity,  as  I  had  expected  to  find. 

Whether  the.  discharge  is  blood  or  serum  at  first,  or  a  mixture  of 
both,  it  is  generally  odorless ;  but  after  a  time  it  becomes  fetid,  and 
remains  so  persistently.  The  fetor  appears,  from  the  testimony  of 
most  observers,  to  be  peculiar ;  but  I  have  not  been  able  to  distinguish 
it  from  the  smell  of  putrilage  of  other  jDroductions.  When  all  these 
symptoms  unite  they  form  a  case  almost  unmistakable.  Lancinating 
pain,  sero-sanguineous  discharge,  and  peculiar  fetor,  continuing  per- 
sistently, are  almost  distinctive  of  cancer. 

I  cannot  lay  much  stress  on  either  one  of  these  symptoms ;  but  of 
the  three  the  most  importance  should  be  attached  to  the  fetor.  Per- 
sisting for  weeks  it  should  cause  us  to  suspect  a  cancer.  Contempo- 
raneous with  the  complete  estabUshment  of  these  symptoms  we  have 
constitutional  suffering.  It  is  not  often,  I  think,  that  general  suffer- 
ing precedes  the  local  symptoms  of  cancer,  and  it  has  always  seemed 
to  me  to  follow  as  the  effect  of  local  disease.  It  has  not  been  my  lot 
to  meet  with  the  broken-down  constitution  sometimes  said  to  be  gen- 
erated by  the  cancerous  diathesis.  Cancerous  antemia,  causing  the 
straw-colored  translucency  of  the  skin,  considered  characteristic  of  the 
malignant  cachexia,  is  not  distinguishable  from  the  hemorrhagic 
anaemia  occurring  sometimes  in  persons  of  the  same  age,  produced  by 
the  drain  upon  the  blood. 

In  the  fully-developed  condition  of  carcinoma  the  constitution 
suffers,  and  the  collection  of  symptoms  are  such  as  arise  from  the 
embarrassment  and  failure  of  the  functions  in  a  long  struggle  with 
pain,  loss  of  blood,  anxiety,  and  inaction.  Debilit}^,  with  indigestion, 
palpitation,  restlessness,  neuralgia,  constipation  at  first,  colliquative 
diarrhoea  and  aphthae  toward  the  end,  nightsweats,  wandering  of 
mind,  unsteadiness  of  purpose,  succeeded  by  delirium  and  apathy  ;  in 
fact,  all  the  train  of  symptoms  which  precede  dissolution  when  it  ap- 


676  CANCER  OF  THE  UTERUS. 

proaches  through  protracted  struggles,  in  which  pain  and  exhausting 
discharges  are  the  destroying  agencies. 

Causes. 

But  little  can  be  said  as  to  the  causes  of  cancer  of  the  uterus.  The 
general  opinion  that  it  is  hereditary  in  most  cases  is,  doubtless,  true; 
and  yet  a  great  many  instances  occur  that  cannot  be  traced  to  such  a 
cause.  This  is  no  reason  why  they  may  not  be  hereditary,  because 
sometimes  the  circumstances  which  permit  the  hereditary  taint  to 
show  itself  do  not  exist  for  a  number  of  generations.  And  again,  the 
taint  may  be  so  dilute  as  to  require  very  favorable  circumstances  or 
co-operating  causes  to  bring  it  out.  If  a  mother  dies  of  cancer  at  the 
age  of  forty-five,  and  impart  the  same  morbid  tendency  to  her  daugh- 
ters, the  laws  of  cell-development  would  bring  it  about  at  the  same  a,ge 
in  the  child.  If,  therefore,  the  daughter  dies  a  year  too  soon  of  some 
other  disease,  the  taint  is  inoperative,  though  present.  Two  or  three  gen- 
erations of  cancer-bearing  persons  cut  off  by  other  diseases  lose  the  his- 
tory of  its  inheritance.  Or  if  a  mother  be  the  subject  of  cancer  at  the 
end  of  a  life  of  active,  nay,  excessive,  child-bearing,  while  her  daugh- 
ter leads  a  life  of  celibacy,  or  has  but  a  single  child,  the  physiological 
life  of  the  two  is  so  different  that  we  would  naturally  expect  some  modi- 
fication of  consecutive  cell-development  to  result.  So  that,  although 
the  hereditary  taint  is  the  same  in  the  two,  their  pathological  ages  may 
differ,  and  the  daughter  may  not  have  cancer  until  a  later  period,  and 
die  before  that  time  arrives.  We  should,  I  think,  allow  much  for 
influences  that  may  modify  hereditary  taints,  and  only  regard  them 
as  hereditary  tendencies,  to  be  brought  out  in  mother  and  daughter 
under  similar  circumstances,  and  which  may  be  postponed  or  pro- 
duced earlier  in  the  one  or  the  other  by  certain  conditions. 

Married  women  are  affected  more  frequently  than  the  single,  and 
the  fruitful  than  the  barren.  When  we  consider  how  many  more 
married  than  single  women  there  are  in  civilized  communities,  and 
how  few  married  women  are  sterile,  we  ought  not  to  attach  much 
importance  to  these  facts.  A  much  more  significant  fact  is  that  a 
very  large  majority  occur  during  the  menstrual  years  of  a  woman's 
life.  It  is  true  that  there  may  be  nothing  more  than  a  mere  coinci- 
dence in  this  fact,  and  that,  after  all,  the  hereditary  mutations  in  the 
system  during  these  years  may  bring  about  cancerous  deposit,  inde- 
pendently of  any  connection  with  the  menstrual  function.  But  it 
certainly  is  a  coincidence,  if  not  an  etiological  coincidence.  As  to 
the  connection  of  cancer  with  chronic  inflammation  and  ulceration  of 
the  uterus,  much  has  been  and  may  be  said.  I  cannot  lay  my  hand 
on  statistics  upon  this  subject,  but  I  have  never  observed  the  coinci- 
dence of  inflammation  and  cancer,  or  that  cancer  was  a  consequence 
of  inflammation.     If,  however,  they  are  occasionally  connected,  there 


DIAGNOSIS.  577 

are  but  few  at  the  present  day  who  believe  cancer  to  be  the  result 
of  long-continued  inflammation. 

Diagnosis. 

It  would  seem  that  the  diagnosis  of  a  disease  so  marked  as  cancer 
would  be  an  easy  matter,  and  so  it  is  when  all  or  even  most  of  the 
peculiarities  of  the  disease  have  been  fully  developed ;  but  in  the  very 
beginning  there  may  be  much  obscurity.  A  patient  complaining  of 
nothing  more  than  a  perfectly  clear,  inodorous,  watery  discharge, 
seemingly  in  the  enjoyment  of  good  health,  would  hardly  be  regarded 
as  a  victim  to  one  of  the  most  surely  fatal  and  loathsome  diseases 
incident  to  the  human  race ;  and  yet  it  is  almost  invariably  so  when 
the  patient  is  advanced  beyond  the  epoch  allotted  to  menstruation. 
The  cancerous  disease,  as  it  usually  occurs,  advances  beyond  the 
period  of  doubtful  symptoms  in  a  very  short  time,  and  in  the  majority 
of  cases  our  attendance  is  not  requested  until  a  scrutinizing  examina- 
tion will  enable  us  to  decide  very  positively  on  the  nature  of  the  case. 
Our  attention  will  be  attracted  by  the  unusual  amount  and  character 
of  discharge,  pain,  and  smell. 

The  following  characteristics  of  beginning  carcinoma  are  given  by 
Stratz :  * 

1.  The  diseased  portion  has  a  definite  and  well-defined  contour,  and  nowhere 
merges  gradually  into  the  healthy  tissue. 

2.  There  is  always  a  perceptible  difference  in  the  diseased  portion  as  a  whole,  and 
the  healthy. 

3.  The  carcinomatous  tissue  always  has  a  yellowish  tinge  of  color. 

4.  The  malignant  spots  show  small,  hard,  yellowish-white  elevations,  at  least  in 
places. 

It  is  not  necessary  to  insist  on  the  importance  of  an  emiy  diagnosis, 
since  it  is  only  in  the  early  stages  that  we  may  hope  to  effect  a  per- 
manent cure. 

Summary  of  appearance  in  cases  from  Becquerel : 

"  Cancerous  Deposit. 

Cervix  hard,  unequal;  nodulated,  os  not  always  open,  sometimes  wrinkled  or  fur- 
rowed. 

Cancer  of  the  neck  often  implicates  the  vagina. 

Hereditary  influence  is  often  traceable. 

Touch  is  painless. 

Discharge  sometimes  absent,  in  certain  cases  very  abundant,  and  consisting,  for  the 
most  part,  of  albuminous  serum. 

Menstruation  increased,  being  neither  more  nor  less  painful,  and  passing  often  into 
the  state  of  real  hemorrhage. 

*  Zeitsch.  f.  Geb.  und  Gyn.,  1886,  vol.  xiii.,  No.  1. 
37 


578  CANCER  OF  THE  UTERUS. 

Absence  of  special  anaemia  when  the  vagina  and  body  of  the  uterus  are  involved. 
Cancerous  cachexia. 

Progress  continuous  and  without  cessation. 

The  pain  in  cancer  is  very  sharp,  intense,  and  lancinating,  and  not  influenced  by 
locomotion  or  movements  of  any  kind." 

"  Ulcerated  State. 

Developed  at  the  critical  period  of  life  generally. 

Preceded  and  accompanied  by  hemorrhages. 

Severe,  sharp,  lancinating  pain. 

Development  essentially  in  sharp  irregularities  and  nodosities. 

Adhesions  to  other  organs  soon  as  ulceration  is  formed ;  immobility  of  the  uterus. 

The  surface  only  slightly  soft;  subjacent  tissue  scirrhous. 

Ulceration  deep,  unequal,  essentially  irregular,  with  thick,  elevated,  and  hard 
edges. 

Always  granulations. 

Discharges  extremely  abundant,  consisting  of  purulent  and  often  sanguineous  serum  ; 
nauseous  and  often  fetid  odor. 

Great  hemorrhage  from  time  to  time,  not  necessarily  at  menstrual  period." 

"  Cancerous  Ulceration. 

Developed  upon  an  hypertrophied  and  scirrhous  surface. 

Ulceration,  deep,  vast,  unequal,  grayish  surface  with  thick  edges,  and  easily 
bleeding. 

Ulcerated  surface  hard,  presenting  numerous  lobes  and  tubercles,  with  nodosities 
and  great  hardness. 

Often  great  loss  of  substance. 

Cervix  and  corpus  uteri  immovable  on  account  of  adhesions. 

Discharges  sanious,  fetid,  sanguinolent,  and  of  an  insupportable  and  characteristic 
odor. 

Cancerous  cachexia  always  present." 


Prognosis. 

The  prognosis  of  cancer  is  a  gloomy  one.  Indeed,  there  is  no  dis- 
ease which  so  uniformly  terminates  fatally  as  cancer  of  the  uterus. 
Notwithstanding  this  fact  forces  itself  upon  our  observation,  there  will 
sometimes,  in  the  course  of  a  large  experience,  occur  a  recovery  from 
it  spontaneously  and  unexpectedly.  I  need  not  enter  into  the  dis- 
cussion of  the  causes  of  this  fatality.  Whether  the  disease  is  essen- 
tially a  blood-disease,  or  whether  primarily  local,  there  are  but  few 
instances  in  which  it  is  not  multilocular.  It  exists  from  the  begin- 
ning, or  very  soon  afterwards,  in  more  than  one  place.  Yet  again, 
this  is  not  invariably  the  case.  We  very  seldom  meet  with  an  in- 
stance in  which  the  area  of  deposit  is  small  and  confined  to  one 
locality.  If  this  locality  is  accessible,  the  case  possibly  is  curable.  I 
say  possibly,  because  the  pathology  is  treacherous.  This  gloomy  pic- 
ture is  in  part  relieved  by  the  greatly  improved  palliative  means  we 


TREATMENT.  579 

now  possess.     Very  much  may  be  clone  to  allay  the  agonizing  state 
of  body  and  mind  under  its  ravages. 

Treatment. 

Both  medicinal  and  surgical  means  fail  to  give  the  profession 
much  satisfaction  in  the  treatment  of  cancer  of  the  uterus.  When 
the  disease  is  clearly  confined  to  the  cervical  portion  of  the  organ, 
amputation  of  that  portion  holds  out  a  very  faint  hope  of  cure.  It  is 
so  common  for  the  cells  constituting  the  main  bulk  of  the  deposit  to 
be  scattered  far  beyond  the  apparent  margin  of  the  disease,  that  much 
more  frequently  than  otherwise  an  abundant  crop  of  them  is  left 
behind  to  continue  the  work  of  destruction.  Very  rare  instances  of 
cure  are  reported. 

While,  then,  it  is  our  duty  to  give  our  patient  even  a  remote  chance 
for  recovery,  we  cannot  hold  out  much  hope  of  radical  cure  by  re- 
moving the  cervix. 

The  same  is  true  in  reference  to  the  operation  for  extirpating  the 
entire  uterus.  The  immediate  danger  attending  the  removal  of  the 
cervix  need  scarcely  enter  into  our  calculation  of  the  benefits  that 
may  arise  from  it.  This  cannot  be  said,  however,  of  the  operation  for 
exsecting  the  whole  uterus.  The  dangers  in  this  operation  are  mani- 
fold, while  the  immunity  from  a  return  can  be  counted  upon  in  only 
a  small  proportion  of  cases.  Nevertheless,  the  recent  improvement  in 
the  statistics  of  vaginal  hysterectomy,  together  with  the  possibility  of 
an  earlier  diagnosis  than  formerly,  are  giving  surgeons  great  encour- 
agement. 

I  do  not  think  the  operation  can  be  sustained  by  success  until  the 
immediate  dangers  are  very  much  diminished.  (For  these  operations 
see  Epithelioma.) 

Can  we  reasonably  hope  for  a  cure  of  cancer  by  medicine?  I  think 
this  question  can  be  unqualifiedly  answered  in  the  negative. 

I  fully  believe  that  the  rapidity  of  growth  may  sometimes  be  re- 
tarded, and  possibly  stayed  for  a  length  of  time.  Many  medicines 
have  enjoyed  the  reputation  of  curing  cancer,  and  have  been  used 
with  implicit  faith,  but  I  may  safely  say  that  not  one  does  at  the 
present  time.  I  need  not  stop  to  inquire  how  such  reputation  could 
have  been  acquired,  except  to  say  that  until  within  a  comparatively 
recent  date  other  and  curable  diseases  were  mistaken  for  cancer. 
Quite  lately  we  have  been  assured  of  the  great  powers  of  cundurango 
in  this  direction,  and  for  a  time  there  were  very  slight  reasons  to  hope 
that  it  was  a  useful  if  not  a  curative  means  in  the  treatment  of  cancer. 
It  has  enjoyed  a  place  in  the  category  of  cures  for  cancer  for  a  shorter 
time  than  many  others. 

Within  a  few  months  a  beam  of  light  has  fallen  upon  the  subject 


580  CAlSrCER    OF    THE   UTERUS. 

which  has  again  awakened  the  hope  that  possibly  we  are  on  the  eve 
of  finding  a  medicine  capable  of  influencing  this  destructive  cell- 
growth. 

Professor  John  Clay,*  obstetric  surgeon  to  the  Queen's  Hospital, 
Birmingham,  has  had  some  very  fortunate  experience  with  Chian 
turpentine  in  uterine  cancer.  The  statement,  coming  from  one  whose 
professional  character,  so  far  as  I  know,  cannot  be  impeached,  and 
published  in  the  staid  old  journal,  the  London  Lancet^  must  command 
general  attention.  Considering  our  experience  in  the  cure  of  cancer 
the  results  obtained  by  him  seem  marvellous,  and  for  fear  of  marring 
the  face  of  his  report  I  abstain  from  making  my  own  summary,  but 
will  quote  his  case  in  full,  together  with  some  of  his  remarks. 

"A  woman  came  to  the  hospital  as  an  out-patient,  aged  fifty-two.  She  was  sufier- 
ing  from  scirrhous  cancer  of  the  cervix  and  body  of  the  uterus.  Hemorrhage  was 
excessive,  pain  of  the  back  and  abdomen  agonizing,  and  cancerous  cachexia  well 
marked.  The  patient  evidently  had  not  a  long  time  to  live.  The  uterus  was  so  ex- 
tensively destroyed  by  the  cancerous  ulceration  that  its  cavity  readily  admitted  three 
fingers.  In  such  a  case  it  appeared  to  be  justifiable  to  attempt  to  relieve  the  suffer- 
ings of  the  patient,  even  if  the  remedy  should  produce  unfavorable  symptoms,  or 
should  prove  of  no  avail.  I  therefore  prescribed  Chian  turpentine,  six  grains;  flowers 
of  sulphur,  four  grains;  to  be  made  into  two  pills,  to  be  taken  every  four  hours.  No 
opiates  were  prescribed  or  lotion  used.  No  change  was  to  be  made  in  her  diet  or 
occupation.  On  the  fourth  day  after  taking  the  medicine  the  patient  reported  herself 
greatly  relieved  from  pain,  and  was  in  better  spirits,  but  she  complained  of  a  large 
amount  of  discharge.  It  was  feared  that  she  referred  to  a  discharge  of  a  sanguineous 
nature.  On  examination,  however,  the  vagina  was  found  to  be  filled  with  a  dirty- 
white  secretion,  so  tenacious  as  to  be  capable  of  being  pulled  out  rope-like,  and  this 
although  she  had  syringed  herself  three  hours  previously.  The  os  was  quite  con- 
tracted and  would  now  scarcely  admit  the  finger,  and  the  surrounding  swelling  or  can- 
cerous infiltration  of  the  cervix  was  much  reduced.  On  the  twelfth  day  the  thick 
tenacious  secretion  had  almost  disappeared,  and  was  succeeded  by  a  somewhat  copious 
serous  fluid.  The  os  was  not  so  firmly  contracted,  but  would  only  admit  the  finger. 
The  patient's  general  health  was  improved  and  the  medicine  well  tolerated.  Sixth 
week:  I  ordered  her  a  quinine  mixture  in  conjunction  with  the  turpentine,  but  sick- 
ness supervened,  which  ceased  on  omitting  the  quinine.  Twelfth  week  :  My  notes 
are, — the  parts  feel  ragged  and  uneven,  and  do  not  bleed  on  roughly  touching  them. 
The  speculum  shows  several  cicatricial  spots.  The  turpentine  has  been  taken  regu- 
larly during  the  day  for  twelve  weeks  every  four  hours,  during  which  time  she  has 
been  almost  free  from  pain  and  has  had  no  hemorrhage;  no  glandular  enlargement; 
general  health  improved.  Walks  easily  to  the  hospital,  being  about  a  mile  distant. 
As  the  patient  did  not  come  again  to  the  hospital  her  address  was  obtained,  and  it 
was  ascertained  that  she  had  left  her  residence.  Being  a  widow  she  could  not  afford 
to  keep  her  home,  and  she  went  to  reside  with  her  married  daughter  in  a  northern 
town,  but  left  no  address.  The  case  showed  that  the  medicine  was  one  of  great  power 
in  cancer  of  the  uterus,  and  it  is  to  be  regretted  that  an  opportunity  was  not  offered  for 
fully  carrying  out  the  treatment. 

"  Another  patient,  aged  thirty-one,  suffering  from  cancer  of  the  os  and  cervix  uteri, 

*  London  Lancet,  June  number,  1880. 


TEEATMENT.  58] 

was  treated  concurrently  with  the  one  just  mentioned.  These  parts  were  enlarged 
from  carcinoma  to  the  size  of  a  hen's  egg.  The  os  was  dilated,  and  the  cavity  of  the 
cervix  was  filled  with  epithelial  growths,  which  bled  freely  on  examination.  Sacral 
pain  was  very  severe,  and  hemorrhage  had  been  continuous  for  the  previous  six  weeks. 
The  Chian  turpentine  and  sulphur  were  given  as  in  the  previous  case.  The  patient 
again  attended  at  the  hospital  on  the  seventh  day  after  taking  the  medicine.  She  was 
in  excellent  spirits,  and  expressed  her  gratitude  for  the  relief  afforded  her.  The  medi- 
cine entirely  relieved  her  pain.  She  had  increased  white  discharge.  On  examina- 
tion the  OS  and  cervix  were  found  to  be  nearly  of  the  normal  size.  The  os  was  patu- 
lous, and  its  surface  was  studded  with  flabby  shot-like  eminences,  which  did  not  bleed 
on  roughly  rubbing  them.  I  said  to  her:  'You  are  better;  you  must  continue  the 
medicine.'  She  answered :  '  I  should  think  I  must,  for  I  could  not  do  without  the 
pills;  they  have  eased  me  so  very  much.'  She  continued  to  improve,  and  on  the 
fourth  week  she  expressed  herself  as  quite  well.  I  impressed  upon  her  the  necessity 
of  continuing  the  medicine,  and  told  her  to  see  me  occasionally.  She  did  not  come  to 
the  hospital  again  for  four  months,  when  she  brought  another  patient  to  consult  me, 
believing  that  she  was  suffering  from  cancer.  I  reproved  her  for  leaving  off  attend- 
ance at  the  hospital.  She  answered  that  she  thought  it  unnecessary,  as  she  had  con- 
tinued quite  well.  On  this  visit  she  submitted  to  an  examination.  The  os  was  rough 
and  irregular,  but  was  of  nearly  the  normal  size ;  no  signs  of  cancerous  infiltration ; 
the  periods  were  regular,  and  not  profuse,  and  were  unattended  with  pain ;  there  was 
slight  leucorrhcea.  This  case  was  a  most  remarkable  one.  The  turpentine  acted  upon 
the  growth  with  great  vigor,  literally  melting  it  away  in  the  brief  period  of  four  or 
five  weeks. 

"  The  third  case  was  one  of  epithelial  cancer  of  the  os,  cervix,  and  the  body  of  the 
uterus,  in  a  woman,  aged  fifty-two  years.  The  vagina  was  not  involved.  The  mass 
was  larger  than  a  cricket-ball,  almost  filling  the  vagina.  The  border  of  the  os  was 
three-quarters  of  an  inch  in  thickness,  forming  a  ring  of  two  and  a  half  inches  in 
diameter,  through  which  protruded  an  epithelial  growth,  pi-incipally  proceeding  from 
the  anterior  wall  of  the  uterus,  and  projecting  about  two  and  a  half  inches  into  the 
vagina.  The  case  was  sent  to  the  hospital  for  my  opinion  by  my  son,  Mr.  Langsford 
Clay,  who  had  attended  the  patient  but  a  short  time.  The  journey  to  the  hospital 
fatigued  her  very  much,  and  she  declared  that  she  could  not  come  again,  and  that  she 
did  not  wish  to  remain  as  an  in-patient,  believing  that  she  could  not  live  many  days. 
She  had  repeated  hemorrhages,  had  much  pain,  and  had  the  cancerous  cachexia  well 
pronounced.  My  son  volunteered  to  attend  her  at  home,  and  I  agreed  to  see  her 
occasionally  with  him.  I  thought  it  advisable,  as  an  experiment,  to  vary  the  treat- 
ment somewhat,  and  ordered  to  be  added  to  the  pills  one-sixth  of  a  grain  of  the  ammo- 
niated  copper,  as  from  the  large  mass  to  be  acted  upon  I  thought  that  an  astringent 
should  be  superadded  to  the  turpentine.  The  dirty-white,  tenacious  discharge,  appeared 
and  continued  for  the  first  five  weeks,  but  there  was  no  hemorrhage  after  the  first 
examination.  The  swollen  os  uteri  and  the  cervix  beyond  were  the  first  to  show  signs 
of  diminution  ;  this  was  noted  on  the  fourteenth  day.  The  tumor,  however,  was  rough 
and  shrunken,  and  did  not  project  so  much.  Sixth  week:  The  surface  of  the  tumor 
was  at  the  level  of  the  os  uteri,  and  seemed  to  consist  of  a  mass  of  bloodvessels,  which 
bled  moderately  after  examination.  This  condition  occasioned  me  some  surprise,  as 
three  weeks  previously  the  patient  was  ordered  a  lotion  made  with  perchloride  of  iron, 
with  a  view  to  arrest  hemorrhage,  since  from  her  anaemic  condition  it  was  feared  that 
the  loss  of  a  moderate  amount  of  blood  would  be  followed  by  serious  consequences. 
I  asked  her  what  kind  of  a  syringe  she  used  with  the  lotion.  She  replied,  '  I  thought 
the  lotion  was  merely  to  bathe  the  external  parts.'  This,  as  it  happened,  was  very 
satisfactory  information,  as  it  showed  that  the  lotion  had  no  share  in  the  reduction  of 


582  CANCER  OF  THE  UTERUS. 

tlie  mass,  which  now  was  scarcely  half  the  original  size.  She  was  supplied  with  a 
syringe  for  the  purpose  of  applying  the  lotion,  and  after  using  it  three  days  the  mass 
of  vessels  had  considerably  shrunken,  and  no  longer  bled  on  manipulation ;  but  the 
surface  of  the  growth  had  the  touch  and  appearance  of  a  gangrenous  mass,  but  there 
was  scarcely  any  fetor.  The  patient  now  complained  of  gastrodynia,  with  colicky 
pains  in  the  bowels,  but  she  had  no  diarrhoea  or  vomiting.  1  believed  this  to  be  due 
to  the  copper,  and  it  was  consequently  discontinued.  It  also  appeared  to  me  that  the 
turpentine  might  not  be  efficiently  digested  in  the  solid  form,  and  that  it  would  be 
better  if  the  remedy  were  administered  in  a  state  of  minute  subdivision,  as  in  the  form 
of  an  emulsion.  An  ethereal  solution  of  Chian  turpentine  was  prepared  by  dissolving 
one  ounce  of  the  turpentine  in  two  ounces  of  pure  sulphuric  ether  (anaesthetic).  The 
ether  dissolved  the  turpentine  instantly.  This  solution  was  given  to  our  skilful  dis- 
penser, Mr.  Whinfield,  with  a  request  that  he  would  prepare  a  pleasant  mixture  or 
emulsion  from  it ;  and,  after  a  few  trials,  he  prepared  one  which  is  not  unpleasant  to 
take,  according  to  the  following  formula :  Solution  of  Chian  turpentine,  half  an  ounce ; 
solution  of  tragacanth,  four  ounces  ;  syrup,  one  ounce ;  flowers  of  sulphur,  forty  grains  ; 
water  to  sixteen  ounces ;  one  ounce  tliree  times  daily.  This  form  of  mixture  was 
given  to  the  patient,  and  was  much  liked.  She  has  now  taken  the  turpentine  for 
thirteen  weeks  uninterruptedly.  The  os  uteri  is  a  little  more  than  one  inch  in  diame- 
ter, and  feels  like  a  ring  of  cartilage  about  a  quarter  of  an  inch  in  thickness.  The 
tumor  has  nearly  disappeared,  and  the  finger  can  be  introduced  posteriorly  into  the 
uterus  for  more  than  an  inch.  The  general  health  has  much  improved,  and  she  is 
quite  free  from  pain  and  looks  cheerful,  and  is  becoming  stouter.  No  sedative  what- 
ever has  been  given  during  the  treatment.  Fourteenth  week:  She  complained  of 
severe  ' cramp-like  pains'  in  the  back  and  lower  part  of  the  abdomen,  which  she 
attributed  to  the  mixture,  and  in  consequence  it  was  discontinued  for  a  few  days,  and 
an  opiate  given,  by  which  she  was  greatly  relieved.  The  turpentine  was  again 
resumed.  Nineteenth  week :  She  is  now  fairly  convalescent.  The  growth  has  almost 
disappeared,  and  the  parts  beyond  the  os  uteri  are  somewhat  hypertrophied,  yet  are 
almost  normal  to  the  touch. 

"The  fourth  case  was  that  of  a  patient  aged  thirty-two  years,  who  came  to  the  hos- 
pital after  having  been  discharged  as  incurable  from  the  Women's  Hospital.  She  was 
greatly  depressed,  and  was  most  desirous  to  be  cured,  for  the  sake  of  her  family  of 
young  children.  She  has  had  repeated  floodings,  and  suffered  greatly  from  pain  dur- 
ing the  past  five  months.  Constipation  very  troublesome,  which  probably  arose  from 
the  opiates  she  had  been  in  the  habit  of  taking.  On  examination,  she  was  found  to  be 
suffering  from  epithelial  cancer  of  the  os  and  cervix  uteri,  but  not  involving  the  vagina. 
There  was  a  cancerous  mass  of  the  posterior  parts  of  the  os  and  cervix,  of  the  size  of 
a  goose-egg.  This  growth  pushed  the  os  uteri  towards  the  pubis,  almost  preventing 
that  part  from  being  felt.  The  turpentine  mixture  was  given  her  three  times  daily, 
and  from  this  period  a  very  rapid  diminution  of  the  growth  took  place,  so  that  by  the 
sixteenth  day  it  had  almost  entirely  disappeared.  The  os  uteri  was  now  in  situ,  admit- 
ting the  finger  readily,  and  there  was  the  same  condition  of  the  vessels  as  that  observed 
in  the  preceding  case.  The  lotion  with  the  perchloride  of  iron  was  used  daily  for  a 
few  days  with  excellent  effect.  In  the  ninth  week  the  patient  suffered  from  spasmodic 
pains  in  the  back  and  abdomen,  and  as  this  was  attributed  to  the  medicine,  it  was  dis- 
continued, and  iodide  of  calcium,  in  five-grain  doses,  three  times  daily,  was  administered. 
This  was  taken  for  about  a  fortnight,  but,  not  feeling  so  well,  the  patient  was  admitted 
into  the  hospital.  The  condition  of  the  internal  organs  was  now  much  the  same  as 
before  the  iodide  of  calcium  was  given,  but  there  was  some  thickening  about  the  cervix, 
which  was  fixed  to  the  vagina.  The  rectum  was  excessively  loaded,  and  required 
several  days  to  effectually  relieve  iti     The  Chian  turpentine  was  administered  simply ; 


TREATMENT.  583 

but  a  lotion  was  prescribed,  containing  six  grains  of  white  arsenic  to  one  pint  of  water, 
to  be  used  daily.  Under  this  treatment  the  woman  very  rapidly  improved,  the  pains 
entirely  ceased,  and  the  parts  became  much  reduced  in  size,  and  more  movable.  The 
patient  was  now  anxious  to  leave  the  hospital  for  her  home,  as  she  felt  quite  well ;  but 
it  was  deemed  advisable  to  send  her  to  the  Sanatorium  instead.  She  is  very  active, 
cheerful,  and  happy,  and  may  be  pronounced  convalescent. 

"  Other  cases  are  under  treatment,  both  in  the  hospital  and  privately,  all  showing 
similar  effects.  The  remedy  is  now  being  tried  in  cancer  of  other  organs,  and  ap- 
parently with  good  results.  One  of  the  most  interesting,  perhaps,  is  a  case  of  scirrhus 
of  the  breast,  which  has  been  under  observation  for  some  weeks.  Among  the  other 
cases  are  cancer  of  the  vulva,  stomach  and  abdomen,  in  which  very  remarkable  benefit 
has  been  already  produced. 

"  From  the  results  obtained  by  the  use  of  Chian  turpentine,  it  may  be  confidently 
said  that  the  remedy  does  exert  a  powerful  action  on  cancer  of  the  female  generative 
organs  in  particular,  and  it  will  be  of  advantage  to  point  out  some  of  the  conclusions 
at  which  I  have  arrived  respecting  the  efficacy  of  the  drug,  and  the  manner  in  which 
it  should  be  employed.  The  oil  of  turpentine,  if  it  produces  any  effect  on  cancer,  is 
inadmissible  on  account  of  the  speedy  production  of  its  specific  effects  even  when 
administered  in  small  doses.  The  same  remark  applies  with  less  force  to  the  Venice 
and  Strasbourg  turpentines ;  in  my  hands  they  have  not  produced  the  same  beneficial 
effects  on  cancerous  growths  as  the  Chian  turpentine  has  done.  The  maximum  dose 
of  the  last-named  drug  which  can  be  safely  and  continuously  given  is  twenty-five 
grains  daily.  It  is  advisable  to  discontinue  the  remedy  for  a  few  days  after  ten  or 
twelve  weeks'  constant  administration,  and  then  to  resume  it  as  before.  The  combina- 
tion with  sulphur  was  given  at  first,  and  has  been  continued.  It  is  doubtful  whether 
much  benefit  is  derived  from  the  combination,  but  the  effects  have  been  so  uniformly 
good  with  it,  that  it  was  thought  advisable  to  continue  its  use.  There  is  every  reason 
to  believe,  from  the  trials  made  with  otiier  substances  in  combination  with  the  turpen- 
tine, such  as  carbonate  of  lime,  iodide  of  calcium,  ammoniated  copper,  quinine,  ber- 
berine,  hydrastin,  etc.,  that  the  turpentine  is  best  administered  simply,  as  the  most 
marked  and  rapid  effects  have  always  been  manifested  when  it  has  been  given  alone. 

"  The  turpentine  appears  to  act  upon  the  periphery  of  the  growth  with  great  vigor, 
causing  the  speedy  disappearance  of  what  is  usually  termed  the  cancerous  infiltration, 
and  thereby  arresting  the  further  development  of  the  tumor.  It  produces  equally 
efficient  results  on  the  whole  mass,  seemingly  destroying  its  vitality,  but  more  slowly. 
It  appears  to  dissolve  all  the  cancer  cells,  leaving  the  vessels  to  become  subsequently 
atrophied,  and  the  firmer  structures  to  gradually  gain  a  comparatively  normal  con- 
dition. 

"  It  is  a  most  efficient  anodyne,  causing  an  entire  cessation  of  pain  in  a  few  days, 
and  far  more  effectually  than  any  sedative  that  I  have  ever  given.  In  the  cases  I 
have  described  no  sedative  was  employed  in  any  instance,  although  in  some  cases 
where  great  pain  had  existed  previously  to  commencing  the  treatment,  large  doses  had 
been  given.  Whether  this  arrest  of  pain  arises  from  the  death  of  the  tumor,  or,  as  my 
son  suggests,  is  due  to  there  being  no  longer  irritation  of  the  sentient  nerves  (in  conse- 
quence of  tension  being  withdrawn  by  the  removal  of  the  cells),  the  fact  is  the  same. 

"If,  after  the  use  of  the  remedy  for  some  weeks,  one  of  these  cases  were  examined 
by  a  stranger  for  the  first  time,  he  would  probably  conclude  that  it  was  one  of  com- 
mencing malignant  disease,  by  reason  of  the  irregularities  of  its  surface.  The  effect 
of  the  remedy  being  first  to  remove  the  cellular  structures,  any  loss  of  tissue  produced 
by  the  invasion  of  the  disease  cannot  be  restored,  and  hence  the  irregular  touch  and 
appearance  even  after  cicatrization.  The  arrest  of  the  hemorrhagic  discharge  and  the 
remarkable  freedom  from  glandular  affections,  after  a  lengthened  use  of  the  turpentine 


584  CAJS'CEE   OF    THE   UTERUS. 

are  especially  important  fectors  in  materially  aiding  the  removal  of  the  cachexia,  and 
of  improving  the  general  condition  of  the  patient. 

"  Without  being  in  position  to  affirm  that  the  Chian  turpentine  is  a  positive  cure 
for  advanced  cancer  of  the  female  generative  organs,  yet,  however,  the  facts  here 
adduced  may  be  interpreted  in  this  respect,  two  circumstances  are  indisputable — one, 
that  all  the  patients  after  several  months'  treatment  are  living,  and  that  the  disease 
has  not  advanced  as  is  usually  the  case,  but  has  retrogressed — in  fact,  has  all  but  disap- 
peared ;  and  it  may  at  least  be  safely  asserted  that  when  the  remedy  is  steadily  used 
for  some  time  it  arrests  the  progress  of  the  disease,  and  relieves  the  pain  incidental  to 
the  morbid  growth  in  a  manner  which  cannot  be  said  of  any  other  remedy.  It  is 
probable  that  on  an  extended  experience  of  its  use  and  by  variations  of  the  mode  of 
administration,  it  may  prove  an  effectual  cure  for  this  intractable  disorder.  Patience 
and  perseverance  on  the  part  of  the  patient  and  medical  adviser  are  absolutely  required. 
We  know  that  in  some  diseases,  as  bronchocele  and  syphilis,  a  long  continuance  of 
well-known  remedies  is  often  necessary  to  effect  a  cure  of  the  particular  disorder,  and 
that  the  administration  of  the  remedies  has  to  be  varied  from  time  to  time,  according 
to  the  therapeutic  effects  produced  by  the  drugs.  In  cancer,  as  far  as  experience  has 
at  present  indicated,  the  same  alternating  method  may  perhaps  have  to  be  employed. 
Whatever  may  be  the  ultimate  results  there  can  be  no  doubt  that  Chian  turpentine  in 
these  disorders  is  a  most  valuable  medicine.  Judging  by  my  experience  it  is  no  figura- 
tive expression  to  say  that  it  acts  as  a  direct  poison  upon  the  growth,  probably  causing 
its  ultimate  death.  In  advanced  cancer  the  process  of  reparation  is  slow,  but  if  the 
surrounding  structures  are  not  too  much  involved  in  the  process  of  destruction,  it  will 
seem  that  a  cure  may  be  reasonably  expected.  It  is  not  that  the  remedy  has  failed 
against  the  cancer,  but  that  the  vital  organs  are  so  much  destroyed  that  their  complete 
reconstruction  and  adjustment  of  functions  are  not  possible,  and  life  fails  in  conse- 
quence of  their  mutilated  condition.  Even  under  these  circumstances,  if  the  cancer 
does  not  recur,  the  efficacy  of  the  medicine  is  obvious.  In  the  early  stages  of  cancer 
it  may  be  affirmed  that  an  undoubted  cure  may  take  place  speedily,  and  as  the  con- 
tiguous structures  are  not  extensively  involved,  but  little  deformity  ensues ;  and  experi- 
ence justifies  the  expectation  that  under  such  circumstances  a  recurrence  of  the  disease 
will  not  follow. 

"  The  history  of  the  local  treatment  of  cancer  of  the  uterus  is  one  of  singular  interest, 
and  is  highly  instructive  to  the  practical  physician.  The  contrast  between  the  general 
and  local  treatment  is  the  more  notable,  as  nothing  can  be  more  injurious  to  the  welfare 
of  the  patient  than  an  attempt  to  destroy  the  cancer  by  external  agencies.  The  disease 
is  not  to  be  averted  by  this  means,  as  the  symptoms  assume  a  more  intense  and  threat- 
ening character,  until  the  patient  rapidly  sinks.  It  may  be  observed  that  the  internal 
treatment  here  recommended  when  used  for  a  considerable  period  is  borne  by  the  patient 
with  remarkable  tolerance.  As  I  have  mentioned,  in  some  of  my  experiments  I  de- 
termined, in  order  most  thoroughly  to  test  the  medicine,  to  reply  upon  this  alone. 
Recently  the  arsenical  lotion  has  been  superadded,  and  with  no  injurious  consequences 
— it  appears  to  act  as  a  disinfectant,  and  it  may  produce  some  benefit  by  promoting  the 
cicatrization  of  the  tissues.  Several  suggestions  offer  themselves  for  inquiry  as  to  aid- 
ing locally  the  detachment  of  the  growth,  after  its  vitality  has  been  destroyed  ;  but  this 
is  not  of  much  importance,  as  there  seems  to  be  no  fear  of  the  blood  becoming  affected 
by  the  absorption  of  the  decaying  tissues,  the  turpentine  probably  preventing  any  such 
calamitous  occurrence. 

"  If  the  practice  now  described  should  prove  by  future  experience  to  be  justified, 
then  it  will  be  incumbent  upon  the  medical  adviser  to  treat  cancer  of  the  generative 
organs  at  an  early  stage  of  its  development,  and  it  is  reasonable  to  conclude  that  this 
dreaded  and  most  fatal  disease  will  no  longer  be  the  scourge  it  has  hitherto  proved, 


PALLIATION.  585 

and  that  another  benefit  will  have  been  conferred  upon  suffering  humanity  by  the 
resources  of  therapeutic  art." 

Professor  Clay  has  recently  publislied  several  cases  in  which  he  claims 
a  cure  by  the  use  of  this  remedy. 

Palliation. 

There  comes  a  time  in  the  progress  of  cancer  of  the  uterus  that  the 
patient  is  prostrated  by  the  septic  effects,  caused  by  absorption  of  gan- 
grenous products  at  the  surface  of  the  degenerating  mass.  When  this 
is  the  case  we  may  often  relieve  the  patient  more  by  removing  all  the 
dead  and  dying  tissue  with  a  sharp  curette  and  thermo-cautery  than 
in  any  other  way.  To  do  this  the  vagina  should  be  dilated  with  Sims's 
or  Simon's  speculum  until  the  parts  are  thoroughly  exposed.  Then 
with  the  sharp  curette  we  should  gouge  out  and  remove  in  detail  all 
the  diseased  substance  down  to  the  solid  tissue  of  the  cervix,  and  then 
cauterize  the  whole  surface  with  the  thermo-cautery.  In  this  way,  for 
a  time,  we  get  rid  of  the  hemorrhage,  the  fetid  discharge,  and  often  the 
distressing  pain. 

After  this  the  patient's  general  health  will  almost  always  be 
greatly  improved,  and  she  will  have  a  happy  respite  from  her  terrible 
suffering. 

'    This  operation  may  be  repeated  once  or  oftener,  as  the  conditions 
seem  to  justify. 

One  who  has  never  tried  this  method  of  relieving  the  patient  would 
very  naturally  be  deterred  from  resorting  to  it  by  fear  that  the  hem- 
orrhage would  be  dangerously  profuse.  A  trial,  however,  will  prove 
to  him  that  this  apprehension  is  groundless.  If  the  curetting  part 
of  the  operation  is  done  briskly  there  will  not  generally  be  much 
hemorrhage,  and  the  benefits  resulting  from  it  will  far  exceed  the  ill 
effects  of  the  loss  thus  incurred. 

I  mention  this  as  the  first  and  most  important  palliative  measure 
to  which  we  can  resort,  as  the  comfort  of  the  patient  will  be  promoted 
to  a  greater  extent  than  by  a  resort  to  any  other. 

Palliation  of  the  pain,  smell,  and  debility,  is  the  object  of  the  most 
of  our  treatment.  For  pain  we  use  local  remedies,  introduced  into  the 
vagina.  Opium,  belladonna,  cicuta,  hyoscyamus,  and  Indian  hemp, 
may  all  be  used  locally.  The  best  form  for  their  application,  is  that 
of  a  bolus  of  five  grains  of  pul.  opii.  We  may  instruct  the  patient  to 
introduce  the  finely  powdered  opium  through  a  small  glass  tube,  with 
a  piston  of  whalebone  and  cotton.  It  is  applied  thus  to  the  ulcerated 
part  and  to  the  walls  of  the  vagina  in  the  neighborhood,  and  very 
effectually  acts  as  an  anodyne.  Ten  grains  of  the  extract  of  hyoscy- 
amus may  be  used  as  a  bolus,  or  two  grains  of  ext.  belladonna  j  and 


586  CAXCEE,  OF  THE  UTERUS. 

SO  on  with  all  the  anodynes.  A  grain  of  morphia  may  be  mixed  with 
the  ext.  hyoscyam.  to  great  advantage. 

Medicated  injections  often  soothe  the  diseased  part  very  much  also. 
The  watery  extract  of  opium  may  be  thrown  into  the  vagina  by  a 
small  syringe,  and  allowed  to  remain,  the  patient  lying  on  her  back 
for  a  length  of  time.  Hydrocyanic  acid  in  solution,  gtt.  xx  to  a  pint 
of  water,  passed  through  the  vagina,  has  a  very  pleasant  effect  some- 
times. Injections  of  vapors  of  the  anaesthetics  are  highly  recom- 
mended, particularly  by  Professor  Simpson.  Carbonic  acid  gas  and 
chloroform  are  those  most  used. 

The  chloroform  vapor  may  be  passed  through  the  vagina  by  the 
ordinary  perpetual  syringe,  made  by  the  Union  Rubber  Company. 
The  chloroform  should  be  placed  in  the  bottom  of  a  large  bottle, 
while  the  receiving-tube  of  the  syringe  may  be  passed  through  the 
cork  and  made  air-tight  with  wax.  The  other  end,  being  inserted  in 
the  vagina,  high  enough  to  almost  come  in  contact  with  the  disease, 
the  pumping  may  be  commenced.  The  vapor  will  be  caused  to  rise 
in  the  bottle  quite  rapidly  under  the  exhausting  influence  of  the 
syringe.  Care  should  be  taken  not  to  let  the  tube  deep  enough  in 
the  bottle  to  come  in  contact  with  the  chloroform,  lest  this  fluid,  in- 
stead of  its  vapor,  pass  through  the  instrument.  The  vapor  thus  de- 
livered into  the  vagina  causes  a  sense  of  heat  and  glow,  which  very 
soon  seems  to  replace  the  pain.  When  properly  done,  patients  expe- 
rience great  relief  from  this  gaseous  injection.  The  same  apparatus 
will  do  to  convey  carbonic  acid  gas  to  the  parts.  The  gas  is  gener- 
ated by  mixing  in  the  bottle  carb.  soda  and  tart,  acid,  and  then  pour- 
ing a  little  water  upon  it.  Although  I  have  never  yet  tried  the  effect 
of  great  cold  to  the  part,  I  have  no  doubt  it  would  be  very  effective 
in  relieving  the  pain.  It  should  be  applied  through  the  speculum 
directly  to  the  parts  diseased,  and  no  other.  A  small  amount  of  the 
freezing  mixture,  of  two  parts  pounded  ice  and  one  part  common 
salt,  in  a  small  muslin  bag,  is  the  means  used  by  Professor  Simpson, 
It  is  thought  this  cold  not  only  relieves  the  pain,  but  that  it  retards 
the  advance  of  the  disease  somewhat.  The  contact  should  be  con- 
tinued until  the  parts  assume  a  pale,  bloodless  appearance,  when  this 
is  practicable,  and  may  be  used  twice  or  three  times  in  twenty-four 
hours.  With  the  local  remedies  for  pain  may  be  mentioned  the  sub- 
cutaneous injection  of  morphia  over  the  sacrum,  or  in  the  iliac  region. 

All  local  remedies  for  pain  will,  after  awhile,  fall  short  of  the  relief 
demanded  by  our  suffering  patients,  and  we  will  be  under  the  neces- 
sity of  introducing  them  into  the  system  in  a  more  effective  manner. 
We  must  resort  to  their  internal  use.  I  need  not  mention  the  ano- 
dynes to  which  we  would  resort  in  such  cases ;  they  are  well  known 
to  the  profession.  I  would,  however,  caution  the  student  not  to  use 
opium  when  any  of  the  others  will  answer   the   purpose.     Indian 


PALLIATION.  587 

hemp  will  be  found  to  do  this  more  frequently  than  any  of  the  others. 
They  will  all  fail,  eventually,  and  opium  will  prove  the  great  blessing 
in  such  cases.  And  let  me  add  the  further  caution :  to  commence 
with  as  small  doses  as  will  -answer  the  purpose ;  and  while  we  deal 
liberally  enough  with  the  drug  to  get  its  good  effects,  increase  it 
slowly  as  possible,  for  with  all  our  precautions  in  this  respect  we  will 
be  under  the  necessity  of  giving  it  enormously.  The  anaesthetics  are 
too  evanescent  to  be  relied  upon  for  main  remedies,  but  they  will 
render  the  influence  of  opium  more  prompt,  and  perhaps  lasting. 

The  hemorrhage  of  cancer  will  sometimes  require  prompt  inter- 
ference. I  think,  however,  that,  although  the  bleeding  is  always 
ultimately  exhausting,  it  is  seldom  immediately  dangerous  from  its 
copiousness.  I  have  generally,  when  the  hemorrhage  required  in- 
terference, depended  upon  the  introduction  of  small  pieces  of  ice  fre- 
quently repeated.  It  is  often  very  grateful  to  the  patient  as  well  as 
hsemostatic.  Dr.  Simpson  recommended  powdered  tannin  introduced 
through  the  speculum  and  placed  on  the  part ;  but  he  places  more 
dependence  on  a  paste  made  of  perchloride  of  iron  and  glycerin.  If 
the  bleeding  should  be  very  alarming,  notwithstanding  these  means, 
the  tampon  would  be  our  last  resort. 

The  ofiFensive  odor  emanating  from  the  disease  makes  it  very  de- 
sirable to  have  some  means  of  correcting  it.  I  should  remark,  with 
reference  to  the  plans  often  resorted  to,  that  they  are  more  or  less  in- 
jurious to  the  patient  and  attendant,  viz.,  the  burning  of  sugar,  myrrh, 
etc.,  in  the  room.  This  should  be  done  very  sparingly.  For  the  air, 
chloride  of  lime,  and  good  ventilation  will  do  better  than  all  other 
expedients.  We  do  not  wish  to  make  a  stronger  smell  less  offensive, 
to  be  sure,  but  we  desire  to  remove  the  effluvia.  Burnt  sugar  simply 
fills  the  room  with  various  other  less  offensive  gases,  while  we  breathe 
with  them  the  original  cause  of  the  trouble.  Chlorine,  disengaged 
from  the  chloride  of  lime,  probably  destroys  the  material  floating  in 
the  air  that  offends  the  sense  of  smell.  But  the  emanation  may  be 
lessened  by  the  use  of  carbolized  water  as  a  wash  and  injection.  Fre- 
quent changes  of  the  linen  and  bedding  of  the  patient  are  matters  of 
cleanliness  that,  of  course,  will  readily  suggest  themselves. 

Septicaemia  is  the  condition  which  most  commonly  causes  the 
greatest  suffering  and  hurries  the  patient  towards  a  fatal  issue.  Any 
palliative  measure,  therefore,  which  enables  us  to  stay  or  modify  its 
course,  will  prove  a  source  of  great  relief.  The  absorption  of  the 
liquid  products  of  the  necrosed  and  sloughing  tissue  eliminated  from 
the  surface  of  the  ulcer  is  the  cause  of  the  septic  fever ;  hence  a  most 
important  item  in  the  palliative  treatment  of  cancer  is  to  keep  the 
surface  of  the  ulcer  as  free  from  dead  and  fungous  substance  as  pos- 
sible. This  may  and  ought  to  be  done  by  removing  it  with  the 
sharp  curette  as  often  as  necessary.     When  we  operate  for  the  re- 


588 


CANCER   OF   THE   UTEEUS. 


moval  of  the  necrosed  substance  and  fungus,  the  parts  should  be  well 
exposed  by  Sims's  or  Simon's  retractor  speculum,  the  vagina  thor- 


FlG.  274. 


Fig.  275. 


il 


i 

II 

111 


Sharp  Curette. 


Simon's  Curette. 


OUghly  washed  out,  and  then  freely  sponged  with  the  tincture  of  iron. 
This  will  enable  us  to  see  the  line  of  demarcation  bet\Yeen  the  sound 


PALLIATION.  589 

and  dead  tissue.  Then  with  Simon's  spoon  every  portion  of  the  rotten 
substance  should  be  freely  removed.  During  the  operation  frequent 
washing  away  of  the  blood  will  be  necessary,  that  we  may  see  what 
we  are  doing.  When  the  ulceration  is  extensive,  and  making  its  way 
toward  the  bladder  or  posterior  peritoneal  cul-de-sac,  it  will  require 
care  to  avoid  opening  one  of  these  cavities. 

Although  I  have  done  this  palliative  operation  a  great  many  times, 
I  have  not  seen  an  excessive  loss  of  blood  or  any  other  serious  con- 
sequence follow  it.  It  is  always  better,  however,  to  be  prepared  with 
means  by  which  to  check  the  bleeding,  and  probably  the  best  is  the  ■ 
thermo-cautery.  If  this,  or  some  other  form  of  cautery,  cannot  be 
commended,  and  hemorrhage  is  sufficient  to  require  an  haemostatic, 
a  tampon  of  cotton,  saturated  with  a  solution  of  the  persulphate  of 
iron,  may  be  advantageously  used. 

It  is  surprising  how  much  relief  this  little  operation  generally 
affords.  The  patient  w^ill  often  be  so  much  improved  as  to  indulge  in 
the  hope  that  she  is  recovering  from  her  loathsome  disease.  In  a 
greater  or  less  time,  however,  the  symptoms  will  return,  and  may  be 
again  relieved  by  the  operation. 

When  a  case  is  advancing  slowly,  this  process  of  cleansing  the  ulcer 
may  be  profitably  and  safely  resorted  to  a  number  of  times.  We 
ought  not  to  try  to  remove  any  of  the  tissue  beneath  the  ulcerated 
surface,  but  confine  the  operation  to  the  scraping  away  of  the  necrosed 
substance.  This  same  operation  is  applicable  to  cases  in  which  there 
are  frequent  hemorrhagic  discharges.  It  generally  checks,  and  some- 
times permanently,  losses  of  this  kind,  especially  if  followed  by  the 
use  of  the  actual  cautery  or  the  thermo-cautery.  The  history  of  can- 
cer discloses  many  disappointments  in  so  called  cures  of  this  terrible 
malady.  The  more  recent  discoveries  of  this  kind  are  jaborandi  and 
the  Chian  turpentine.  The  former  temporarily  tempted  the  credence 
of  the  more  sanguine  of  the  profession,  but  after  repeated  trials  has 
been  condemned  as  utterly  worthless. 

The  Chian  turpentine,  which,  on  account  of  the  great  respectability 
of  its  early  advocate,  seemed  to  hold  out  a  faint  hope  that  we  were  on 
the  threshold  of  a  valuable  discovery,  has  been  found  wanting  also. 
That  the  progress  of  cancerous  deposit  will  ever  be  arrested  by  medi- 
cine is  a  problem  for  the  future.  That  true  cancer  of  the  uterus  can 
be  cured  by  any  kind  of  surgical  operation  is  yet  to  be  proven.  Can- 
cerous deposit  in  the  uterus,  if  not  the  result  of  blood  disease,  is  a 
focus  from  which  widespread  contamination  emanates  in  every  direc- 
tion, to  an  extent  that  surgery  cannot  reach. 

Such  is  the  melancholy  paucity  of  our  resources  in  cancer  of  the 
uterus.  Scarce  as  they  are,  however,  they  may  afford  the  sufferer 
great  comfort;  and  we  should  fall  short  of  our  duty  if  we  did  not  in- 
dustriously employ  them,  as  the  best  the  profession  can  afford. 


CHAPTEK  XXXVL 


EPITHELIOMA,  CANCROID,  EPITHELIAL  CANCER  OF  THE  UTERUS. 

All  these  terms,  with  many  others,  are  applied  to  a  fungoid  devel- 
opment in  and  upon  the  mucous  membrane  of  the  uterus.  It  is 
essentially  an  excessive  and  modified  proliferation  of  the  epithelial 
cells,  which  destroys  the.  membrane  upon  which  it  grows,  and  sloivly 
penetrates  adjoining  structures. 

Its  development  is  not  by  interstitial  deposit,  as  in  other  varieties 
of  cancer,  but  consists  of  superficial  accumulations  and  soft  deposits 
of  epithelial  cells,  held  together  by  very  dehcate  connective  tissue. 

Fig.  276. 


[Epithelioma  of  Uterus. 


The  shape  of  the  deposit,  or  growth,  varies.  In  some  instances  it 
is  thinly  spread  over  a  large  surface,  while  in  others  it  grows  out  as 
a  fungus  from  a  restricted  area.  In  the  former  instance  the  whole 
mucous  membrane  of  the  cavity  of  the  uterus  may  be  overlaid  and 
permeated  by  it.  from  the  external  orifice  to  the  fundus,  and  thus  be 
converted  into  a  flat,  frialde  covering  of  the  deeper  structure;  while 
in  the  latter  there  may  be  fungi,  of  greater  or  less  size,  projecting 


EPITHELIOMA CANCROID. 


591 


from  the  mucous  membrane  of  the  uterine  cavity ;  but  much  more 
frequently  they  spring  from  one  of  the  cervical  labia,  or  the  whole 
cervical  circle. 

The  substance  of  the  membrane  thus  diseased  is  generally  hyper- 
trophied,  but  not  otherwise  very  much  changed  in  character,  until 
the  disease  has  made  great  progress  on  the  membrane  itself.  When 
the  disease  is  situated  in  the  endometrium,  the  body  of  the  uterus  may 
be  enlarged  for  a  long  time,  and  not  be  attached  to  the  other  organs. 
When  the  growth  occupies  the  external  membrane  of  one  of  the  cer- 
vical labia  the  submucous  structure  is  sometimes  increased  so  that  it 

Fig.  277. 


Epithelioma  of  the  Cervix. 

may  project  into  the  vagina  much  beyond  its  ordinary  extent.  This 
will  give  the  appearance  of  a  large  fungus,  while  it  is  really  the  hyper- 
trophied  lip  covered  with  cancroid  deposit.  At  other  times  the  labium 
is  not  so  much  enlarged,  while  the  fungus  projects  down  sufficiently 
to  partially  or  wholly  fill  the  vagina. 

In  all  of  these  varieties,  after  a  time,  the  more  superficial  parts  of 
the  growth  undergo  a  process  of  necrosis  and  slough  off.  The  parti- 
cles thus  sphacelated,  together  with  sanguineous  and  mucous  fluids, 
constitute  the  discharges  from  epitheliomatous  surfaces. 

Disintegration  of  this  sort  is  generally  accompanied  with  further 


592 


EPITHELIAL   CANCER   OF   THE  UTERUS. 


growth,  so  that  the  size  of  the  deposit  is  not  materially,  if  at  all, 
diminished. 

Fig.  278. 


Fungus  Growing  from  the  Cervix. 


When  the  process  of  disintegration  has  fairly  begun,  the  disease 
becomes  developed,  and  gradually  the  role  of  septic  symptoms  super- 
venes, and  carcinomatous  dyscrasia  is  established. 


Diagnosis. 

The  symptoms  of  epithelioma  are  the  same  as  in  other  forms  of  can- 
cer. They  have  already  been  described,  and  I  need  not  reproduce 
them  here.  We  may  differentiate  epithelioma  from  other  forms  of 
cancer  by  examination  with  the  finger  and  sound.  In  epithelioma 
there  is  an  absence  of  the  irregular  hardness  caused  by  the  submucous 
deposit,  by  the  presence  of  a  soft,  friable  projection  into  the  vagina,  or 


DIAGNOSIS — PEOGNOSIS. 


593 


the  same  kind  of  substance  occupying  the  whole  of  the  cervix,  not 
indurated,  but  somewhat  enlarged.  When  this  substance  exists  in 
the  mouth  of  the  uterus,  we  may  ascertain  how  far  it  extends  by 
passing  the  sound  through  it  into  the  cavity.  The  resistance  to  the 
instrument  will  be  slight,  yet  sufficient  to  impart  that  feeling  of 
resistance  caused  by  its  passage  through  a  yielding  tissue.  If  the 
deposit  is  confined  to  the  cervix  the  slight  opposition  to  the  advance 

Fig.  279. 


structure  of  Epithelioma. — From  Cornil  and  Ranvier. 


of  the  instrument  will  cease  before  it  reaches  the  uterine  cavity.  If  it 
extends  to  the  fundus  the  resistance  will  continue  the  whole  depth  of 
the  organ. 

I  can  imagine,  although  I  have  not  met  with  such  a  case,  that  a 
polypus  in  a  gangrenous  condition  might  embarrass  us  somewhat  in 
making  a  diagnosis.  The  use  of  the  microscope  would  clear  up  the 
difficulty  in  such  a  case.  A  very  small  piece  pinched  off  from  the 
mass  will  suffice  for  examination.  In  the  disintegrated  substance  of 
the  polypus  we  find  the  debris  of  fibrous  tissue,  while  the  cells  of 
epithelioma  would  be  found  in  the  malignant  growth.  If  a  sarcoma- 
tous polypus  should  occupy  the  vagina  the  microscopic  test  would  be 
equally  decisive. 

From  a  decaying  placenta,  arrested  in  the  os  uteri,  we  may  distin- 
guish the  epithelioma  by  means  of  the  microscope,  in  case  any  doubt 
should  arise. 

Prognosis. 

The  prognosis  is  not  so  hopeless  as  in  the  other  varieties  of  cancer 
of  the  uterus,  as  it  is  usually  localized.  In  the  earlier  stages  at  least 
it  is   occasionally  amenable  to  treatment.     Without  treatment  it  is 

38 


694 


EPITHELIAL    CANCER   OF   THE    UTERUS. 


equally  fatal,  as  the  morbid  process  is  progressive  to  an  unlimited 
extent. 

Treatment. 

The  treatment  of  epithelioma  of  the  uterus,  as  just  intimated,  is  much 
more  promising  than  the  other  cancerous  affections.  The  curative 
treatment  consists  in  removing  the  whole  of  the  diseased  tissue,  and 
when  this  is  practicable  we  may  reasonably  indulge  a  hope  of  success. 

Fig.  280. 


Dr.  Paquelin's  Thermo-cautery. 


This  can  generally  be  done  when  the  morbid  deposit  is  confined  to  the 
vaginal  portion  of  the  cervix,  and  sometimes  when  it  extends  to  the 
fundus  of  the  uterus.  The  means  we  possess  by  which  this  may  be  ac- 
complished are  the  knife,  the  scissors,  the  sharp  curette,  ecraseur, — 
wire  or  chain, — the  galvano-cautery,  and  the  thermo-cautery,  or  the 
actual  cautery. 

I  have  performed  the  operation  for  removing  epithelioma  by  all  these 
different  instruments  separately,  and  by  using  several  of  them  in  the 
same  operation. 

Dr.  John  Byrne,  of  Brooklyn,  in  a  very  interesting  article  pub- 
lished in  the  second  volume  of  the  Transactions  of  the  American 
Gynecological  Society,  advocates  the  exclusive  use  of  the  galvano- 
cautery.  He  gives  a  number  of  cases  illustrated  by  his  method  of 
operating,  and  of  the  success  following  it.  The  results  are  very 
encouraging,  and  at  the  time  his  plan  was  published  it  was  regarded  as 


TREATMENT. 


595 


most  promising.  He  exposed  the  cervix  by  his  speculum,  and  ampu- 
tated it  with  his  cautery  knife,  heated  by  the  battery  to  a  temperature 
that  made  it  assume  a  dull  red  color;  or,  surrounding  the  cervix,  or 
that  portion  to  be  removed  by  the  platinum  wire,  and  then  applying 
the  battery  so  as  to  heat  it  to  the  same  temperature.  In  doing  the 
operation  according  to  the  latter  method  the  cervix  is  fixed  by  the 
vulsellum,  and,  if  movable,  drawn  down  to  a  convenient  distance 


Fig.  281. 


Fig.  282. 


Byrne's  Cautery  Battery, 


Byrne's  Cautery  Ecraseur. 


from  the  vulva,  and  the  wire,  while  cold,  placed  around  the  cervix  as 
high  as  possible  not  to  include  the  utero-vaginal  junction.  In  this 
position  the  wire  is  tightened  while  cold,  and  then  heated.  Before 
heating  the  wire  the  constriction  should  be  increased  slowly  until  the 
wire  has  fairly  imbedded  itself  into  the  included  tissue. 

Quite  forcible  traction,  exerted  by  the  vulsellum,  should  be  main- 
tained while  the  wire  is  slowly  passing  through  the  substance  of  the 
neck.  This  will  cause  the  central  portion  of  the  amputated  cervix 
to  be  divided  higher  than  the  periphery,  and  the  cavity  will  be 
conoid  in  shape  with  the  apex  in  the  centre.     If  the  disease  is  not  all 


596 


EPITHELIAL  CANCEE  OF  THE  UTERUS. 


removed  by  this  operation  the  cautery  knife  may  be  applied,  as  dif- 
ferent parts  are  drawn  down  by  hooks,  until  the  operator  is  assured 
that  all  the  disease  is  removed,  or  that  the  operation  is  carried  as  far 
as  the  integrity  of  the  bladder  and  peritoneal  cavity  will  allow. 

The  prominent  dangers  in  performing  this  operation  are  hemor- 
rhage, wounding  the  peritoneal  cavity,  and  oi3ening  the  bladder.  The 
first  may  be  avoided  by  having  the  temperature  of  the  wire  low.  If 
it  is  white  hot  it  will  cut  the  tissues,  including  the  arteries,  without 
closing  the  latter.  But  if  of  a  dull  red  heat  it  will  coagulate  the 
albumen  in  the  areolar  tissue,  and  the  blood  in  the  arteries,  some  dis- 


FlG.  283. 


U     ^ 

Byrne's  Cautery  Electrodes. 


tance  from  the  wire.  In  this  way  the  vessels  will  be  sealed  and 
primary  hemorrhage  avoided.  To  avoid  wounding  the  bladder  or 
peritoneum,  I  am  in  the  habit  of  applying  the  wire  with  the  cervix  in 
its  normal  position,  and  making  traction  after  the  wire  has  been  drawn 
tight  enough  to  fix  it  firmly  in  its  bed.  If  we  are  careful  to  apply 
the  wire  in  this  way,  there  is  not  much  danger  of  accident.  When 
the  disease  does  not  extend  to  the  junction  between  the  vagina  and 
uterus,  this  is  an  admirable  method  of  removing  the  cervix.  The 
objections  I  make  to  the  galvano-cautery  are,  that  it  requires  more 
skill  in  the  management  of  the  battery  than  most  practitioners  possess ; 
that  the  burnt  surface  is  so  changed  we  are  unable  to  judge  whether 


TREATMENT.  597 

at  the  point  of  separation  all  of  the  disease  has  been  removed  or 
not;  that  it  is  cumbersome  as  a  portable  instrument,  and  that  it  is  no 
better  in  any  resiDect  and  not  so  manageable  as  the  thermo-cautery, 
I  think  also  that  the  great  heat  generated  in  the  vagina  is  not  without 
objection.  The  advantages  are  that  it  destroys  the  cell  growth  some 
distance  above  the  surface  of  the  amputated  stump,  and  the  opera- 
tion is  entirely  bloodless.  I  have  not  employed  it  in  my  recent  opera- 
tions. 

In  removing  the  cervix  for  epithelioma,  it  will  be  very  convenient, 
however,  to  have  the  galvano-cautery,  or  the  thermo-cautery,  as  one 
of  the  instruments,  but  if  we  intend  to  thoroughly  remove  the  disease, 
and  especially  if  it  extends  above  the  vagino-uterine  junction,  I  think 
we  can  remove  it  more  safely  with  the  scissors  or  knife,  or  both. 

If  there  is  much  of  a  tumor  projecting  into  the  vagina,  I  generally 
apply  the  ecraseur  around  it,  and  include,  if  possible,  the  whole  of 
the  vaginal  neck  within  its  grasp.  I  use  the  chain  instead  of  the  wire 
in  the  ecraseur  because  I  find  it  much  easier  to  manage.  We  should 
be  very  careful  in  the  adjustment  of  the  chain  to  avoid  injuring  the 
bladder  or  penetrating  the  peritoneal  cavity.  In  thi^  part  of  the 
operation  the  galvano-cautery  may  be  used  in  place  of  the  ecraseur. 
If  we  use  the  ordinary  ecraseur,  there  is  no  need  of  dilating  the  vagina 
with  any  sort  of  speculum ;  but  if  we  use  the  hot  wire,  then  the  vagina 
should  be  well  dilated  by  Sims's  speculum,  Simon's  retractor,  or  Bryne's 
speculum.  After  as  much  as  possible  of  the  vaginal  cervix  has  been 
removed  in  this  way,  the  most  important  part  of  the  operation  is  just 
begun,  because,  in  most  cases  we  will  not  be  sure  of  having  removed 
all  the  diseased  tissue.  The  surface  from  which  the  neck  has  been 
thus  removed  should  be  examined  thoroughly.  We  can  do  this  best 
by  seizing  it  with  the  vulsellum  or  single  hooks  and  drawing  it  down 
as  low  as  possible,  where  it  can  be  thoroughly  examined.  It  will  also 
insure  precision  to  examine  the  portion  arpputated  from  the  cervix  to 
ascertain  whether  any  of  the  diseased  tissue  was  cut  through,  or 
whether  the  cut  surface  is  all  sound  or  not. 

If  we  can  assure  ourselves  in  this  way  that  the  disease  is  all  removed 
we  have  little  else  to  do  than  secure  our  patient  from  hemorrhage.  In 
my  own  operations  I  have  had  no  trouble  with  any  of  the  arteries 
divided.  They  usually  spirt  pretty  freely  for  a  few  minutes,  and  then 
gradually  cease  bleeding.  I  do  not  make  this  statement  to  encourage 
carelessness  as  to  hemorrhage,  because,  in  exceptional  instances  the 
hemorrhage  is  dangerously  profuse.  Hence,  as  a  precaution  against 
hemorrhage,  and  for  the  purpose  of  destroying  the  cell  growth  deeply, 
we  should  apply  the  cautery  at  a  dull  red  heat  all  over  the  amputated 
surface  and  be  suj^plied  with  peroxide  of  iron  tampons.  If  we  find  by 
the  examination  of  both  amputated  surfaces  that  we  have  not  removed 
all  of  the  disease,  or  if  we  have  any  doubt  upon  the  subject,  we  should 


598  EPITHELIAL   CANCER   OF    THE    UTERUS. 

seize  point  after  point  of  the  remaining  portion  of  the  uterus  and  cut 
it  off  with  the  scissors,  and  thus  excavate  the  supra-vaginal  cervix  and 
body  of  the  uterus  as  high  as  practicable,  or  until  we  are  satisfied  that 
all  the  disease  is  removed.  By  the  frequent  examinations  as  we  pro- 
ceed in  this  part  of  the  operation,  while  the  whole  is  held  down,  we 
can  keep  within  the  peritoneal  covering  of  the  uterus.  In  opera- 
ting in  this  way,  we  should  often  introduce  the  sound  to  determine 
the  direction  and  depth  of  the  uterine  cavity  above  the  excavation. 
The  sound  will  serve  as  an  excellent  guide  to  our  progress.  If  the 
vagina  is  roomy  enough,  we  may  sometimes  have  the  sound  held  there 
most  of  the  time.  After  we  have  excavated  to  the  desired  extent,  we 
should  char  the  surface  of  the  artificial  cavity  with  the  thermo-cautery. 
Dr.  H.  C.  P.  Wilson,  of  Baltimore,  has  invented  an  ingenious  shield, 
with  which  the  cautery  is  surrounded,  to  prevent  the  heat  from  affect- 
ing the  parts  anywhere  except  at  the  point  of  contact.  Wilson's  shield 
is  a  very  useful  addition  to  Paquelin's  thermo-cautery. 

This  operation  should  be  repeated  as  soon  as  evidence  of  the  return 
of  the  disease  is  apparent.  Often  when  the  cavity  of  the  uterus  has 
been  curetted  free  from  the  epithelial  deposit,  that  organ  contracts, 
and,  to  some  extent,  obliterates  the  cavity  formed  by  the  excavation, 
and  the  area  of  the  disease  becomes  less  each  time.  In  such  cases  we 
may  repeat  the  operation  with  more  prospect  of  removing  the  whole 
of  the  disease  than  in  the  first ;  and  even  the  third  or  fourth  opera- 
tion may  thus  advantageously  be  performed.  Recent  experience  leads 
me  to  attach  much  importance  to  the  very  free  use  of  the  solution 
of  the  pernitrate  of  mercury.  Small  pellets  of  absorbent  cotton  satu- 
rated with  that  fluid  are  placed  in  contact  with  the  scraped  surface, 
supported  by  larger  pieces  of  dry  cotton.  These  large  pieces  we  use 
in  such  position  and  in  such  quantities  as  to  completely  protect  the 
sound  parts,  by  absorbing  the  free  acid.  I  am  encouraged  in  this 
recommendation  by  the  fact  that  epithelial  cancer  may  occupy  the 
mucous  membrane  for  a  long  time  without  vitiating  the  substructure 
deeply. 

I  prefer  this  before  any  other  medicine,  because  it  is  absorbed  and 
acts  as  a  local  alterative  upon  the  lymphatics  and  the  juices  surround- 
ing the  parts. 

Formidable  as  this  operation  really  is,  I  have  not  seen  it  followed 
by  untoward  symptoms  of  any  kind.  In  many  cases  I  have  excavated 
the  uterus  entirely  above  the  internal  os  until  the  walls  became  very 
thin  in  every  direction,  and  many  others  to  a  less  extent.  Opening 
the  peritoneal  cavity  and  bladder  is  one  of  the  dangers  in  the  progress 
of  this  operation.  This  can  be  avoided  by  care.  Hemorrhage  is 
probably  the  only  other  danger,  and  with  Paquelin's  thermo-cautery, 
or  the  galvano-cautery,  at  hand  we  can  easily  check  it  by  touching 
the  bleeding  artery. 


TREATMENT.  599 

The  operation  may  be  followed  by  dangerous  shock,  primary  or 
secondary  hemorrhage,  metro-peritonitis,  cellulitis,  or  septicaemia. 
For  the  treatment  of  all  these  conditions,  except  hemorrhage,  the 
reader  is  referred  to  ovariotomy. 

Injections  of  carbolized  water,  sufficient  to  keep  the  vagina  well 
cleansed,  is  all  that  will  be  found  necessary  to  secure  the  patient  from 
blood-poisoning. 

Ordinarily  the  cavity  is  filled  up  in  two  or  three  weeks,  and  the 
wounded  cervix  covered  with  a  firm  cicatrix.  In  some  instances, 
however,  the  process  of  malignant  degeneration  goes  on,  and  we  are 
restricted  to  palliative  measures  for  the  rest  of  the  patient's  life. 

The  operation  of  Dr.  W.  H.  Baker,  of  Boston,  is  thus  summarized  by 
him  in  the  eighth  volume  of  the  American  Gynecological  Society  Trans- 
actions. After  drawing  down  and  fixing  the  cervix  he  disects  out  the 
supra-vaginal  portion  anteriorly  to  the  level  of  the  internal  os,  sepa- 
rating it  from  the  bladder  with  scissors  aided  by  the  forefinger  then 
proceeding  posteriorly  working  in  the  same  manner  in  the  cellular 
tissue  up  to  the  same  level.  The  posterior  and  anterior  incisions  are 
then  to  be  united  by  lateral  incisions  which  prepares  the  cervix  for 
complete  removal.  "  Having  done  this  I  cut  away  the  cervix  by 
means  of  the  uterotome  (or  scissors)  removing  a  cone-shaped  portion 
from  the  body  of  the  uterus.  It  thus  becomes  possible  to  remove 
from  one-third  to  one-half  of  the  body  of  the  uterus  without  cutting 
into  the  peritoneal  cavity  or  opening  the  bladder.  At  this  point,"  he 
he  says,  "  I  applied  the  thermal  cautery  to  the  stump  at  a  red  heat. 
Applied  at  a  red  heat  I  think  we  are  able  to  destroy  the  structure  be- 
neath quite  effectually.  After  a  thorough  application  of  the  cautery 
the  patient  is  put  to  bed  and  left  undisturbed.  We  have  controlled 
the  hemorrhage,  and  within  the  space  of  two  weeks  the  slough  comes 
away  and  we  have  a  clean  granulating  surface  left."  Dr.  Baker  cites 
six  cases  that  have  remained  cured  for  five  or  six  years.  I  have 
operated  this  way  fifteen  times,  and  can  count  five  cures  of  from  four 
to  six  years'  standing. 

Koeberle,  in  the  Nouv.  Arch,  d'  Ohst.  et  de  Gynecologic  for  J  886,  ex- 
presses himself  strongly  against  total  extirpation  of  the  uterus  for 
cancer,  saying  the  necessity  of  it  is  exceedingly  rare.  In  reading  his 
article  one  would  think  that  he  scarcely  if  at  all  believed  in  the  pro- 
priety of  total  extirpation  of  the  uterus  for  cancer.  He  says  cancer 
of  the  uterus  usually  begins  in  the  cervix  and  extends  to  the  vagina 
and  adjoining  parts  before  it  reaches  above  the  level  of  the  internal 
OS.  Primary  cancer  of  the  body  of  the  uterus  does  not  often  occur, 
and  when  it  exists  the  cervix  is  not  invaded  for  a  long  time.  Just  so 
long  as  the  diseases  in  the  cervix  remains  localized,  and  does  not 
extend  to  the  vagina,  broad  ligaments  or  the  lymphatic  glands  which 
communicate  with  the  lymphatic  vessels  of  the  uterus,  so  long  is  the 


600  EPITHELIAL   CANCER   OF   THE    UTERUS. 

body  of  that  organ  sound,  and  it  is  absolutely  useless  to  remove  it. 
On  the  other  hand,  in  case  of  primary  carcinoma  of  the  body  of  the 
uterus  or  of  epitheliomic  fungosities,  etc.,  of  the  mucous  membrane, 
the  cervix  being  sound,  it  is  useless  to  remove  it. 

Total  extirpation  of  the  uterus,  whether  by  laparotomy  or  through 
the  vagina,  being  admittedly  more  difficult  and  more  dangerous  than 
the  removal  of  either  the  cervix  or  body,  hysterectomy  should  be  re- 
served for  those  special  cases  where  partial  hysterotomy  will  not 
suffice  for  the  removal  of  the  entire  disease.  Abdominal  hysterotomy 
— for  the  removal  of  the  uterus — is  applicable  to  those  very  rare  cases 
in  which  the  disease  commences  in  and  is  confined  to  the  body  of 
that  organ,  while  vaginal  hysterotomy  is  the  resort  in  those  more  fre- 
quent instances  where  the  disease  has  commenced  in  and  is  limited 
to  the  cervical  portion  of  the  uterus. 

He  has  performed  extirpation  of  the  cervix  nine  times.  In  two  the 
cancer  returned,  and  in  one  time  enough  had  not  elapsed  to  decide 
whether  it  would  return  or  not.  He  mentions  one  case  of  epithelioma 
of  the  uterine  cavity  in  which  he  removed  the  uterus  by  abdominal 
section  in  1875  with  no  recurrence  to  date.  In  1882  he  performed 
successively  vaginal  extirpation  of  the  cervix  and  abdominal  extirpa- 
tion of  the  body  of  the  uterus.  The  patient  recovered  from  the  two 
operations,  and  has  not  had  a  return  of  the  cancer.  Koeberle's  opera- 
tion for  cancer  of  the  cervix  is  essentially  the  same  as  that  of  Dr. 
Baker  above  described. 

After  some  observations  with  the  more  powerful  caustics  of  potash 
and  zinc,  I  would  caution  the  inexperienced  against  the  introduction 
into  the  vagina  of  agents  so  destructive  and  difficult  to  limit.  Their 
action  may  and  is  likely  to  extend  beyond  desirable  bounds.  There 
can  be  no  question  as  to  the  choice  between  them  and  the  actual 
cautery  in  some  form.  The  operator  can  see  and  control  the  effects 
of  the  cautery,  and  thus  limit  it  to  the  desired  extent,  which  cannot 
be  said  of  these  powerful  caustics.  The  less  severe  forms  of  caustic, 
such  as  the  solution  of  the  pernitrate  of  mercury  may  serve  an  excel- 
lent purpose  without  much  danger  of  too  destructive  effects. 

I  have  twice  operated  by  removing  epitbeliomatous  fungus  that 
pervaded  the  whole  mucous  lining  of  the  uterine  cavity,  in  which 
there  has  been  no  return  of  the  disease  after  four  years.  With  a 
sharp  curette  I  thoroughly  and  carefully  removed  the  whole  of  the 
diseased  material  (after  having  inverted  the  uterus  in  one  case),  and 
then  filled  up  the  cavity  with  cotton  saturated  with  the  solution  of  the 
pernitrate  of  mercury.  One  of  the  patients  was  fifty-five  years  of  age 
and  the  other  forty-three.  In  three  other  cases  operated  on  this  way 
the  disease  returned ;  one  within  three  months,  one  in  about  twelve 
months,  and  in  the  other  the  disease  did  not  seem  to  be  arrested. 

In  using  the  solution  the  cotton  should  be  divided  into  small  pellets 


TREATMENT.  601 

about  the  size  of  a  Lima  bean,  saturated  with  mercury  and  afterward  the 
free  fluid  pressed  out  between  the  smooth  surfaces  of  two  pine  boards 
and  dried.  When  we  are  ready  to  use  them  they  should  be  secured 
by  strong  cotton  threads  so  they  may  be  easily  removed.  After  the 
scraped  cavity  is  filled  with  these  pieces  of  cotton,  a  large  tampon  of 
surgical  cotton  should  be  passed  up  to  the  cervix  and  the  vagina  be- 
neath it  filled  with  cotton  tampons  saturated  with  glycerin. 

The  j)ernitrate  does  not  destroy  the  tissues  to  which  it  is  applied 
very  deeply,  but  I  believe  it  destroys  the  vitality  of  the  morbid  cells 
much  beyond  its  boundary  as  a  caustic. 

The  pernitrate  dressing  may  be  allowed  to  remain  about  twenty- 
four  hours,  when  everything  should  be  removed  and  the  parts  kept 
clean  by  warm  water  douches  twice  a  da.j. 

If  extirpation  of  the  uterus  is  justifiable  in  any  form  of  malignant 
disease  it  is  so  in  epitheliorha,  for  that  disease  is  often  entirely  local- 
ized in  the  uterus,  and  yet  occasionally  so  situated  that  we  cannot 
remove  the  whole  of  it  by  any  other  operation. 

The  formidable  operation  proposed  by  Freund,  and  practiced  by 
him  and  his  followers,  has  not  been  followed  by  a  success  that  would 
encourage  me  to  perform  it  under  any  circumstances.  We  may  rea- 
sonably hope,  "however,  that  some  method  of  exsecting  the  uterus 
which  will  be  less  difficult  of  performance  and  less  dangerous  in  its 
results  may  be  some  day  invented.  Indeed,  a  long  stride  in  that  direc- 
tion has  already  been  made,  and  is  illustrated  by  an  oj)eration  recently 
performed  by  L.  C.  Lane,  M.D.,  professor  of  Surgery  in  the  Medical 
College  of  the  Pacific.  Dr.  Lane  terms  his  operation  pervaginal  enu- 
cleation of  the  uterus.  That  term  alone  would  mislead  the  reader,, 
for  the  uterus  was  not  enucleated ;  it  was  extirpated,  and  the  opera- 
tion might  very  properly  be  called  colpo-hysterectomy,  or  vaginal  ex- 
tirpation of  the  uterus. 

The  operation  is  very  simple,  and  does  not  involve  the  necessity  of 
extreme  and  protracted  exposure  and   handling  of  the  abdominal 
organs.     The  wounding   of  tissue  is  less  extensive,  and  the  whole 
operation  is  done  in  the  lowest  and  least  susceptible  portion  of  the 
peritoneal  cavity. 

After  placing  the  patient  on  her  side,  in  Sims's  position,  and  dilating 
the  vagina  with  Sims's  speculum.  Dr.  Lane  had  the  uterus  drawn 
down  with  Pean's  tenaculum  forceps,  and  then  made  an  incision 
through  the  posterior  wall  of  the  vagina. 

"The  fundus  was  then  seized  by  the  forceps  and  the  uterus  made  to  revolve  on  its 
transverse  axis,  so  that  the  Fallopian  tubes  and  ovaries  were  brought  down  low  in 
the  pelvic  excavation  in  such  manner  that  the  base  of  the  tubes  and  accompanying 
arteries  became  accessible  and  easily  ligated. 

"  Ligation  was  done  with  a  strong  silken  cord  so  passed  throughi.  button-holes  (?)  in 
the  broad  ligaments  that  they  could  not  afterward  slip  off.     This  portion  of  the  opera- 


602  EPITHELIAL    CANCER    OF   THE    UTERUS. 

tion  was  completed  in  fifteen  minutes,  but  the  detachment  of  the  organ  from  the  blad- 
der was  long  and  tedious,  but  finally  successfully  done  without  opening  that  viscus. 
Yet  so  thin  was  the  remaining  vesical  walls  that  the  lustre  of  the  catheter,  which 
served  as  a  guide,  at  times  could  be  seen.  The  organ  being  removed  the  pelvic  ex- 
cavation was  rinsed  out  with  a  one  per  cent,  solution  of  carbolic  acid,  a  Ndlaton  flexi- 
ble catheter  was  placed  in  the  bladder,  the  pelvic  excavation  was  filled  with  lint, 
saturated  with  four  per  cent,  carbolized  linseed  oil,  and  the  abdomen  covered  with 
india-rubber  ice-bags.  A  drainage-tube  was  so  fixed  alongside  the  carbolized  lint  as 
to  allow  the  escape  of  any  fluids  which  should  be  passed  out  from  the  wounded  surface. 
"The  convalescence  was  uninterrupted." 

The  description  of  the  operation  is  very  imperfect,  yet  I  think  it 
will  not  be  difficult  for  the  reader  to  follow  it  understandingly.  The 
steps  of  the  operation  are :  1.  The  dilatation  of  the  vagina  by  Sims's 
speculum.  I  believe  Simon's  position  and  retractors  would  be  better. 
2.  Fixing  and  traction  of  the  uterus  downward.  3.  Incision  of  the 
posterior  vaginal  wall,  which  should  be  in  the  central  line  and  extend 
from  the  cervix  to  the  recto-vaginal  attachment.  4.  Bringing  the 
fundus  uteri  down  through  the  vaginal  opening  by  vulsellum  forceps. 
5.  Ligating  the  posterior  border  of  the  broad  ligament  near  the  cervix 
uteri,  so  as  to  include  the  Fallopian  tubes,  ovarian  ligaments,  and 
accompanying  arteries.  6.  Separation  of  the  anterior  surface  of  the 
uterus  from  the  bladder. 

The  first  two  steps  of  the  operation  need  no  further  description 
than  is  given  in  the  quotation.  In  the  third  step  of  the  operation  a 
fold  in  the  centre  of  the  posterior  wall  of  the  vagina  should  be  drawn 
forward  by  the  tenaculum,  and  incised  with  scissors.  The  incision 
should  be  perpendicular  with,  instead  of  across,  the  vagina,  and  large 
enough  to  admit  the  finger,  by  which  we  should  be  guided  in  com- 
pleting the  opening  from  the  cervix  to  the  attachment  with  the 
rectum. 

What  we  are  to  avoid  in  making  this  incision  is  the  wounding  of 
a  loop  of  intestine  or  projection  of  omentum,  which  may  occupy  the 
posterior  cul-de-sac,  and,  while  dividing  low  enough,  not  to  wound 
the  rectum.  The  fourth  will  be  facilitated  by  traction  on  the  cervix, 
which  will  bring  the  fundus  downward  and  forward  within  reach  of 
the  finger,  and  then  permit  the  uterus  to  be  retroverted  within  reach 
of  the  forceps.  Drawing  the  fundus  forward,  up  well  toward  the 
pubis,  will  so  twist  and  condense  the  posterior  portion  of  the  broad 
ligament  as  to  make  the  fifth  step  easy  of  accomplishment.  With 
the  posterior  border  of  the  broad  ligament  thus  brought  forward  we 
can  easily  pass  the  needle  containing  the  ligature  from  the  vagina 
backward,  or  from  behind  forward,  and  secure  the  arteries  with  great 
facility. 

Without  some  caution  another  danger  is  that  of  including  the 
ureters  in  the  ligatures.     The  ureters  approach  the  neck  of  the  uterus 


TEEATMENT.  603 

in  passing  to  the  bladder,  and  at  the  anterior  part  of  the  cervix  are 
within  less  than  three  lines.  The  ligature,  therefore,  should  not  be 
more  than  one-quarter  of  an  inch  from  the  cervix. 

The  most  difficult  part  of  the  operation  is  the  separation  of  the 
uterus  from  the  bladder.  The  fibrous  coat  of  the  bladder,  where  it  is 
attached  to  the  uterus,  is  very  thin,  and  great  care  is  required  in  sep- 
arating it  from  the  uterus  not  to  open  the  bladder.  The  direction 
given  by  Freund  should  be  remembered.  He  recommends  making 
an  incision  across  the  anterior  surface  of  the  uterus,  through  the  peri- 
toneum and  connective  tissue.  Then  by  means  of  the  finger  or  handle 
of  the  scalpel,  strip  the  bladder  off  from  the  uterus.  When  the  point 
of  vaginal  attachment  to  the  uterus  is  reached  it  may  be  carefully  sepa- 
rated with  the  knife  or  scissors.  The  separation  of  the  neck  from  the 
vaginal  attachment  and  the  side  will  be  easy  after  the  bladder  is  iso- 
lated. 

It  seems  to  me  that  the  operation  of  Dr.  Lane  would  have  had  a 
better  conclusion  if  he  had  closed  the  wound  either  with  silk  or  wire 
sutures.  The  most  of  the  large  opening  ought  certainly  to  be  closed 
in  this  way,  and  if  the  operation  is  performed  under  carbolized  spray 
it  would  be  better  thus  to  unite  the  whole  of  it. 

Czerny*  the  reviver  of  vaginal  hysterectomy  operates  similarly,  ex- 
cept that  he  begins  by  incising  the  vaginal  wall  around  the  cervix, 
and  separates  the  bladder  from  the  uterus  before  opening  the  sacro- 
uterine pouch.  The  fundus  is  then  turned  back  and  brought  out 
through  the  opening,  the  peritoneum  then  opened  at  the  anterior 
uterine  wall,  the  broad  ligament  ligated  and  the  uterus  cut  out  between 
them. 

Olshausen  removes  the  uterus  without  retroverting  it.  He  draws 
down  the  cervix,  cuts  through  the  vaginal  wall  all  around  it,  and  sepa- 
rates the  bladder  and  rectum  from  the  uterus  with  the  finger.  The 
bleeding  is  then  completely  checked,  the  cervix  drawn  down  until  the 
broad  ligaments  are  felt  to  be  put  upon  the  stretch,  the  j)eritoneum 
punctured  with  scissors,  and  the  opening  enlarged  with  the  fingers. 
An  elastic  ligature  is  then  passed  over  the  left  broad  ligament  by  means 
of  a  hook,  shaped  like  an  aneurism  needle,  the  ligature  tied,  and  the 
broad  ligament  severed  between  it  and  the  uterus.  The  same  is  then 
done  on  the  right  side. 

Leopold  (with  three  deaths  in  forty-two  cases)  operates  similarly 
but  ligates  the  broad  ligament  in  sections,  beginning  below  and  includ- 
ing the  peritoneal  coats. 

Peter  Mueller  made  the  operation  easier  by  cutting  the  uterus  in 
two  halves  by  a  median  longitudinal  incision  with  blunt  pointed 
scissors  or  knife.     The  bleeding  may  be  controlled  by  compressing 

*  Lehrbuch  d.  Frauenkrankheiten.     F.  Winckel. 


604  EPITHELIAL,   CANCER   OF   THE    UTERUS. 

the  uterine  halves,  while  the  broad  ligaments  are  carefully  tied  in  sec- 
tions. 

Fritsch,  whose  statistics  are  unusually  favorable,  incises  first  the 
lateral  vaginal  fornices  and  separates  the  uterus  above  the  uterine 
artery.  After  checking  all  hemorrhage  he  unites  the  lateral  incisions 
by  transverse  ones  in  front  and  behind,  ties  a  rubber  ligature  tightly 
around  the  cervix  in  the  incision,  loosens  the  bladder  from  the  uterus, 
and  after  drawing  the  cervix  well  downward  and  backward,  pulls  the 
fundus  forward  and  out  through  the  vesico-uterine  opening.  The 
broad  ligament  is  ligated  from  above  downward. 

Winckel*  recommends,  as  a  farther  improvement,  the  cutting  out 
of  the  uterus  in  a  spiral  manner.  He  begins  his  incision  in  the 
anterior  vaginal  fornix,  carries  it  around  the  cervix  and  deepens  it 
gradually  as  he  goes  around  and  around.  Each  vessel  is  tied  as  it  is 
cut,  and  the  uterus  is  pulled  down  as  it  becomes  loosened.  The  peri- 
toneum is  easily  opened,  both  before  and  behind,  when  thus  reached, 
and  the  broad  ligaments  can  then  be  seen  and  tied  in  portions. 

When  the  tubes  and  ovaries  can  be  readily  drawn  down  they  should 
also  be  removed,  as  they  may  contain  germs  of  the  disease. 

The  vaginal  edges  when  not  closed  by  sutures  are  merely  drawn 
together  and  supported  by  a  vaginal  tampon  of  iodoform  gauze  (ten 
per  cent.).  The  tampon  may  be  left  in  place  for  six  or  eight  days, 
but  the  vulval  dressings  must  be  changed  frequently  on  account  of 
the  sero-sanguineous  discharge  that  occurs  on  the  first  days  after  the 
operations.  Antiseptic  vaginal  douches  are  used  after  the  tampons 
are  removed. 

Pean  and  his  followers  use  hemostatic  forceps  instead  of  ligatures 
for  the  control  of  the  hemorrhage.  After  opening  the  abdominal 
cavity  the  fundus  is  brought  down  and  out  of  the  posterior  or  anterior 
opening  (as  may  be  the  easier)  the  whole  ligament  clamped  in  a  single 
long  pair  of  forceps  and  severed  between  the  forceps  and  the  uterus. 
If  one  paix  is  not  large  enough,  or  fails  to  prevent  bleeding,  one  or  two 
more  may  be  applied.  If  the  fundus  cannot  be  brought  down  suffi- 
ciently a  pair  may  be  applied  to  the  base  of  each  broad  ligament,  the 
cervix  cut  loose  as  high  as  the  instrument  reaches,  and  the  fundus 
then  turned  down  and  the  remainder  of  the  ligaments  clamped  from 
above.  Curved  forceps  are  sometimes  used  for  the  latter  purpose,  for 
they  do  not  require  the  fundus  to  be  so  completely  turned  out.  Bleed- 
ing vaginal  edges  may  also  be  clamped  by  forceps.  At  the  end  of 
forty-eight  hours  the  forceps  are  all  removed,  and  the  antiseptic  tam- 
pons in  two  or  three  days  afterwards.  After  this  the  vagina  is  gently 
irrigated  two  or  three  times  a  day  and  antiseptic  dressings  applied  to 
the  vulva  and  vaginal  entrance. 

*  Op.  cit. 


TREATMENT.  605 

This  method  seems  to  be  a  decided  improvement  upon  the  others, 
since  it  enables  us  to  operate  naore  quickly  and  therefore  with  less 
shock  and  less  danger  to  the  patient,  and  also  with  less  danger  of 
hemorrhage.  Hemorrhage  and  shock  are  the  chief  immediate  dan- 
gers, sepsis  and  inflammation  the  principal  remote  ones.  Occasionally 
it  may  be  better  to  use  both  ligatures  and  the  hemostatic  forceps  ;  the 
former  for  the  cut  vaginal  edges  and  small  bleeding  surfaces,  the  latter 
for  the  main  parts  of  the  broad  ligaments  and  such  extensive  bleeding 
surfaces  as  can  be  gathered  into  the  jaws  of  one  pair. 

Should  we  desire  to  amputate  the  body  from  the  cervix  this  method 
of  bringing  the  uterus  out  of  the  peritoneal  cavity  would  give  us  an 
excellent  opportunity  with  the  minimum  risk. 

Redner  explains  how  the  favorable  results  in  ovariotomy  led  also 
to  the  removal  of  myoma  and  carcinoma  of  the  uterus  by  laparotomy, 
and  then  how  more  recently  the  unfavorable  results  of  the  method  of 
operating  advocated  by  Freund  led  to  a  neglect  of  laparotomy.  This 
change  was  favored  also  by  the  fact  that  the  large  number  of  cancers 
springing  from  the  cervix  uteri  could  only  be  removed  imperfectly 
and  with  difficulty  by  this  method,  hence  we  have  drifted  back  to  the 
older  practice  of  attacking  the  organ  through  the  vagina.  Redner 
himself  operated  several  years  ago  in  twenty-eight  cases  of  carcinoma 
uteri  through  the  vaginal  wall,  with  almost  invariable  success  (only 
three  deaths,  two  by  infection,  one  by  hemorrhage),  by  supravaginal 
excision  of  the  cervix.  And  once  having  gone  so  far  it  was  but  a  step 
to  remove  the  whole  uterus  through  the  vagina. 

The  prognosis  is  not  only  considered  good  by  Schroeder*  because  the 
mortality  figure  is  so  small,  but  also  because  the  convalescence  is  so 
rapid  and  easy,  for  in  the  cases  cited  only  two  showed  slight  fever, 
and  two  others  mild  symptoms  of  collapse. 

As  to  the  indications  for  such  operative  measures,  Schroeder  advises 
against  interference  when  the  cellular  tissue  of  the  pelvis  is  already 
invaded  by  cancer,  which  must  be  determined  by  careful  palpation. 
He  further  calls  attention  to  the  fact  that  the  larger  the  diseased 
uterus  the  greater  will  be  the  difficulties  by  this  method,  and  the  more 
appropriate  will  Freund's  procedure  become,  and,  at  the  same  time, 
that  in  cases  of  cancer  of  the  cervix  situated  low  down  we  should  be 
more  conservative  in  either  enucleation  or  supravaginal  incision ;  yet 
after  all,  notwithstanding  all  of  the  advantages  of  the  new  procedure, 
the  former  methods  would  still  retain  their  merits,  according  as  they 
might  be  selected  in  particular  cases. 

*  Paper  read  by  Schroeder  (Berlin)  on  "Total  Extirpation  of  the  Uterus  per 
Vaginam  "  in  the  gynecological  section  of  the  fifty-third  Versaramlnng  der  deutsche 
Naturforscher  und  Aertze  in  Danzig,  in  September,  1880.  Keported  in  the  Archives 
fiir  Gynacologie  Sechszehnter  Band,  Drittes  Heft. 


606  EPITHELIAL    CANCER    OF   THE    UTERUS. 

In  Martin's  three  cases  he  found  such  difficulty  that  in  only  one 
case  was  the  operation  complete.  2d  case:  Impossible  to  sever  all 
adhesions ;  portion  of  diseased  tissue  remained  behind.  3d  case :  Same 
kind  of  difficulty ;  conclusion  that  firm  adhesions  and  brittleness  or 
friability  of  the  uterus  contraindicate  the  operation. 

Interrogated  by  Meyerbeer,  Schroeder  says  he  closes  the  vaginal 
opening  with  curved  needle  and  silk,  but  recommends  ligation  of 
ligaments  by  wire. 

Baum  (of  Danzig)  says  he  formerly  operated  successfully  by  supra- 
vaginal incision  seven  times,  without  resulting  fever,  that  in  only 
two  cases  had  he  failed  to  find  a  return,  but  in  the  last  few  months 
had  operated  per  vaginam  four  times,  two  of  the  cases  resulting  in 
death  from  shock  and  septic  peritonitis.  He  oj)erated  after  Billroth's 
manner,  and  in  one  case  removed  the  ovarian  tubes,  but  applied  no 
sutures  in  order  to  allow  better  drainage  of  the  secretions.  A  drain- 
age-tube was  introduced,  through  which,  in  case  of  fever,  the  parts 
were  washed  out. 

Schrceder  favors  sutures  which  do  not  render  septicaemia  more 
liable,  and  insure  against  protrusion  of  intestines. 

Baum  prefers  his  method,  and  thinks  protrusion  of  intestine  can  be 
prevented  by  position. 


CHAPTER    XXXVII. 

SARCOMA. 

Another  variety  of  malignant  disease  of  the  uterus  is  sarcoma.  It 
generally  shows  itself  in  the  form  of  a  tumor,  developed  at  the  expense 
of  the  fibrous  structure  of  the  uterus,  an  apparently  isolated  portion 
of  which  is  infiltrated  by  an  abundance  of  peculiar  cells. 

While  not  encapsulated,  like  the  fibrous  tumors,  these  growths  dis- 
place the  surrounding  tissue,  and  protrude  in  a  submucous  or  sub- 
serous direction  until  they  become,  to  a  greater  or  less  degree, 
pediculated.  When  first  discovered  and  described  these  tumors  were 
denominated  recurrent  fibroids,  because  ablation  did  not  destroy  them. 
Their  recurrence  is,  doubtless,  due  to  the  fact  that,  while  apparently 
isolated,  the  neighboring  tissues  are  permeated  by  the  sarcomatous 
cells.  Instances  of  difluse  sarcoma  are  also  sometimes  met  with  when 
all  the  tissues  of  the  entire  uterus  are  infiltrated. 

The  cases   of  diffuse   sarcoma  with  which  I  have   met  have   all 

belonged  to  the  small-celled  variety,  and  the  process  of  degeneration 

has  spread  from  the  uterus  to  the  surrounding  tissues,  invading  espe- 

'cially  the  connective  tissue  of  the  broad  ligament.     Sarcoma  is  a  less 

frequent  disease  than  carcinoma  or  epithelioma. 

Symptoms. 

Its  early  clinical  history  is  very  similar  to  that  of  the  fibrous  tumor, 
and  is  more  generally  mistaken  for  it  than  any  other  growth.  Serous 
leucorrhoea,  metrorrhagia,  and  enlargement  are  the  main  ones.  Its 
course,  is  usually  rapid,  less  so,  perhaps,  than  cancer,  and  more  so 
than  fibrous  growths.  In  some  cases  it  attains  to  a  large  size  before 
any  peculiar  phenomena  appear.  After  a  time,  especially  if  sub- 
miicous  or  polypoid,  it  begins  to  break  down,  the  discharge  becomes 
offensive  and  copious,  and  the  disease  proves  fatal  in  much  the  same 
way  as  cancer. 

The  general  symptoms  in  the  early  periods  of  development  are  not 
marked,  and  they  only  become  so  after  the  tumor  has  grown  large 
enough  to  interfere  by  pressure  with  the  fecal  and  urinary  excretions, 
or  in  breaking  up  furnish  septic  material  in  such  quantities  as  to 
induce  septicaemia,  when  all  the  disastrous  symptoms  of  that  formid- 
able fever  are  established.  Thus  diarrhoea,  copious  perspiration,  ele- 
vated temperature,  rapid  pulse,  failure  of  the  assimilative  functions, 
and  great  nervous  prostration  tend  to  a  fatal  issue  with  as  much  cer- 
tainty as  any  other  of  the  malignant  aff"ections. 


608 


SARCOMA. 


Diagnosis. 

In  the  commencement  it  is  always  difficult  to  arrive  at  a  correct 
diagnosis.  The  symptoms  are  not  characteristic,  and  until  the  com- 
mencing dissolution  of  the  tumor  are  as  much  like  those  of  fibrous 
tumor  as  they  are  like  carcinoma,  and  when  disintegration  begins  they 
thoroughly  simulate  cancer  or  epithelioma.  The  only  sure  diagnostic 
sign  of  sarcoma  is  afforded  by  the  microscope.     A  portion  of  the  tumor 

Fig.  284. 


Structure  of  Sarcoma. — From  Cornil  and  Ranvier. 

should  be  submitted  to  microscopic  examination,  when  the  character- 
istic cell  may  at  once  be  discovered  (Fig.  284). 

Mr.  Butlin*  makes  the  following  histologic  distinction  between  sar- 
coma and  carcinoma.     He  says : 

"  I  should  then  define  carcinoma  to  be  a  tumor  of  epithelial  origin,  having  generally 
an  alveolar  structure,  and  sarcoma  a  tumor  of  connective-tissue  origin,  formed  gener- 
ally of  embryonic  tissues,  and  without  alveolar  structure.  And,  for  the  minor  differ- 
ences, the  cells  of  carcinoma  generally  resemble  those  of  the  epithelium  from  which  it 
grows;  there  is  little  intercellular  tissue ;  the  vessels  run  in  the  fibrous  tissues,  not 
among  the  cells ;  and  multiplications  of  cells  is  by  endogenous  formation.  On  the 
other  hand,  sarcoma  is  composed  of  round  or  fusiform  or  giant  cells,  and  these  are 
packed,  in  a  more  or  less  abundant  basis ;  the  vessels  are  often  mere  fissures  between 
the  cells,  and  the  cells  increase  in  number  by  division.  These  minor  characters  are 
common,  but  they  are  not  constant.  One  or  otlier  of  them  may  be  absent  in  a  tumor 
of  either  class;  or,  worse,  may  be  present  in  a  tumor  of  the  other  class.  More  com- 
monly it  is  sarcoma,  which  simulates  the  appearance  of  carcinoma ;  but,  fortunately, 
this  feigning  takes  place  most  often  in  textures  where  there  can  be  no  question  of  the 
origin,  and  therefore  of  the  nature,  of  the  tumor.  The  alveolar  structure,  found  in 
some  sarcomas,  is  rarely  so  perfect  as  that  of  most  epithelial  tumors  ;  indeed,  careful 
study  discovers  that  the  tissue  which  surrounds  the  alveoli  is  generally  formed  of  spin- 
dle cells.  There  is,  in  most  cases,  no  real  difficulty  in  assigning  each  tumor  to  its 
class." 

*  Lectures  on  the  Eelation  of  Sarcoma  to  Carcinoma,  by  Henry  Trentham  Butlin, 
F.R.C.S.     American  reprint.     London  Lancet,  February,  188L 


PEOGNOSIS — TREATMENT.  609 

Prognosis. 

The  prognosis  is  no  more  favorable  than  that  of  cancer.  While  in 
many  instances  the  tumor  caused  by  the  morbid  growth  seems  to  be 
quite  isolated,  the  cells  penetrate  the  surrounding  tissue  to  such  an 
extent  as  not  to  be  eradicable. 

The  contamination  of  the  surrounding  tissue  does  not  seem  to  take 
place  by  absorption  and  transmission  of  the  cells,  or  debris  of  the 
sarcomatous  cells,  but  to  be  due  to  the  insinuation  of  the  cells  into 
the  contiguous  substance  surrounding  the  growth.  It  is,  probably, 
always  local  in  its  origin  and  progress.  This  consideration,  if  true, 
would  encourage  us  to  hope  that,  by  ablation  of  all  the  morbid  sub- 
stance, we  might  arrive  at  a  cure. 

Treatment. 

To  be  radical  the  treatment  should  consist  of  the  entire  removal  of 
the  growth.  When  the  disease  is  confined  to  the  uterus,  I  think  the 
most  rational  treatment  would  be  the  removal  of  that  organ.  Hys- 
terectomy would  seem  to  me  to  be  more  promising  in  sarcoma  than  in 
carcinoma. 

In  addition  to  the  general  palliative  treatment,  detailed  under  the 
head  of  cancer,  the  removal  of  sloughing  masses  by  the  curette  and 
scoop,  we  will  often  derive  great  benefit  from  the  free  administration 
of  ergot.  The  contraction  of  the  uterus,  under  the  influence  of  ergot, 
will  do  more  to  clear  out  the  softening  mass  from  its  cavity  than  any 
instrumental  interference.  I  have  in  several  instances  removed  the 
sarcomatous  growth  by  ergot  so  thoroughly  that  the  improvement  of 
the  patient's  health  led  them  to  hope  for  ultimate  recovery.  When 
the  growth  is  submucous,  and  of  the  most  friable  variety,  I  would 
fully  expect  it  to  be  expelled  b}'-  ergot.  It  does  not,  however,  affect 
the  spread  of  the  growth,  and  ultimate  fatal  result. 


39 


CHAPTER  XXXVIII. 

TUMORS  OF  THE  UTERUS. 

Any  organized  growth  within  the  substance  of  the  uterine  walls,  or 
depending  from  or  connected  with  any  of  its  surfaces,  may  be  called 
a  tumor.  This  definition  will  include  polypi  of  all  varieties  and  sizes, 
from  the  mere  granule  that  renders  the  mucous  surface  irregular  by 
its  protrusion,  to  the  growth  which  fills  up  the  uterine  cavity. 

Fibrous  Tumors. 

Fibrous  tumors  of  the  uterus  are  homologous  growths.  They  are 
not  pure  hypertrophies  of  certain  parts  of  the  uterine  tissues.  As 
proof  of  this  the  tumor-tissue  exhibits  too  much  of  the  rudimentary 
character  of  fibres  of  the  undeveloped  kind,  and  there  is  not  a  uni- 
form proportion  of  the  different  constituent  elements.  For  instance, 
we  find  that  some  specimens  are  quite  firm  and  resisting,  while  others 
are  frail.  In  the  firmer  variety,  the  fibrous  element  is  more  abundant 
than  the  connective,  and  these  ought  to  be  denominated  myomatous 
or  muscular  fibrous  tumors,  while  the  term  fibroma  would  be  better 
adapted  to  those  tumors  in  which  the  fibres  of  the  connective  tissues 
preponderate,  and  the  tumor  is  softer. 

The  question  very  naturally  arises :  How  do  those  tumors  origi- 
nate? a  question  that  cannot  be  satisfactorily  answered.  What  we 
know  about  their  "  habits  "  I  will  lay  before  the  reader.  They  occur 
more  frequently  in  persons  between  the  age  of  thirty-five  and  fifty, 
and  are  found  oftener  in  women  of  African  descent  than  in  those  of 
European  or  Asiatic  origin.  From  much  observation  I  am  also  per- 
suaded that  the  long  continuance  of  great  hypersemia  of  the  uterus 
strongly  predisposes  patients  to  fibrous  tumors.  Hence,  we  find  them 
connected  with  sterility,  dysmenorrhoea  and  menorrhagia.  I  know 
that  these  conditions  are  often  the  results  of  fibrous  degeneration,  but 
I  have  had  opportunity  of  watching  many  such  morbid  states  of  the 
uterus,  which,  while  giving  rise  to  other  symptoms,  were  constantly 
attended  with  hypergemia.  In  some  such  cases  after  years  of  suffering 
tumors  were  developed.  One  remarkable  instance  is  in  a  patient  who 
has  been  under  my  eye  for  fifteen  years.  She  is  a  maiden  lady,  now 
forty  years  of  age.  A  few  years  after  she  commenced  to  menstruate, 
she  became  subject  to  hypersesthesia  and  hyperemia  of  the  uterus. 
Although  I  saw  her,  and  made  examination  of  the  uterus  several 
times  a  year  during  these  fifteen  years,  I  discovered  nothing  which 


FIBEOUS   TUMOES. 


611 


induced  me  to  suspect  fibrous  growth  until  three  years  ago.  Then  I 
could  easily  make  out  a  tumor,  with  two  nuclei  of  development  in  the 
anterior  wall  of  the  uterus.  When  first  noticed,  the  tumor  was  half  as 
large  as  an  orange.  It  grew  to  four  times  that  size  in  the  next  twelve 
months.  I  have  seen  so  many  cases  similar  to  this  that  I  cannot  be- 
lieve hyperemia  and  the  development  of  the  tumor  to  be  a  mere  coin- 
cidence. We  know  that  prolonged  hypersemia  is  one  of  the  necessary 
conditions  of  hypertrophy,  and  it  is  hardly  possible  to  have  hyper- 
trophy without  hyperplasia.  It  would  seem,  indeed,  to  be  the  hyper- 
trophy of  the  vortices  or  foci  of  muscular  gyrations  in  the  undeveloped 
condition  of  the  fibrous  structure  which  leads  to  the  formation  of 
these  tumors. 

All  fibrous  tumors  of  the  uterus  have  their  origin  in  the  wall  of  the 
organ.     Some  arise  immediately  in  contact  with  the  mucous  mem- 

FlG.  285. 


Origin  of  Fibroid  Tumors. 

brane,  then  begin  to  intrude  themselves  into  the  cavity  of  the  uterus 
as  soon  as  they  begin  to  grow,  and  become  pediculated  while  yet 
small,  D.  Others  commence  their  growth  beneath  a  very  thin  layer  of 
fibres,  A.  These  are  quite  near  the  mucous  membrane,  but  not  in 
immediate  contact  with  it.  They  very  soon  overcome  the  resistance 
of  the  thin  layer  of  fibres,  and  pushing  the  mucous  membrane  before 
them,  become  pediculated  later  in  their  growth.  If,  however,  they 
are  deeper  in  the  wall,  but  nearer  the  mucous  than  the  serous  surface, 
the  larger  part  of  their  bulk  encroaches  gradually  upon  the  interior 
of  the  uterus,  forming  broad  tumors  that  fill  the  cavity.  They  can 
easily  be  recognized  by  the  finger  after  dilating  the  cervical  canal. 


612  TUMOES    OF   THE   UTERUS. 

All  of  these  varieties  are  submucous  tumors,  but  in  common  profes- 
sional language  the  first  two  are  called  polypi,  while  to  the  last  the 
term  submucous  tumor  is  generally  given.  The  term  intramural  is 
used  to  indicate  the  tumor  that  arises  in  the  centre  of  the  uterine 
wall,  B ;  a  tumor  which  in  its  development  displaces  the  surrounding 
tissues  alike  in  every  direction.  In  point  of  fact  the  exact  central 
mural  tumor  is  very  rare,  the  great  majority  having  their  nidus  ex- 
ternal or  internal  to  the  central  layer.  The  subserous  tumor  varies 
in  its  relative  distance  from  the  peritoneal  surface  in  the  same  manner 
as  the  submucous  from  the  lining  membrane  of  the  uterus.  Hence, 
some  of  them  spring  from  the  outer  surface  of  the  uterine  wall,  are 
suspended  by  a  very  slender  pedicle,  and  covered  only  by  the  peri- 
toneum, E.  Others  are  not  so  pendulous,  but  still  are  enveloped  by 
only  a  very  thin  layer  of  fibres  externally.  If  they  are  still  more 
remote  from  the  peritoneal  surface,  they  merely  show  themselves  as 
bulky  protuberances  on  the  outside  of  the  uterus,  c.  One  more  state- 
ment with  reference  to  position.  They  are  usually  developed  in  the 
wall  of  the  body,  and  comparatively  seldom  have  their  origin  in  the 
cervical  portion  of  the  uterus.     This  statement  is  true  of  every  variety. 

Their  Nature. 

A  dissection  of  these  tumors  enables  us  to  discover  that  they  are 
surrounded  in  most  instances  by  a  well-marked  capsule.  It  ought 
not  to  be  called  a  cyst  for  it  has  not  a  separate  organization,  and  it  is 
formed  by  the  tissues  surrounding  the  tumor,  being  compressed  as 
they-  are  displaced,  until  the  inner  surface  of  the  cavity  becomes 
smooth.  At  a  number  of  points  the  capsule  and  surface  of  the 
growth  are  connected  by  frail  fibrillse  and  vessels.  The  number  and 
magnitude  of  these  connecting  fibres  and  vessels  vary,  but  it  is  ex- 
ceedingly uncommon  for  vessels  of  considerable  size  to  enter  any  of 
these  tumors,  and  the  vascular  supply  is  proportionately  small.  From 
these  facts  the  logical  deductions,  namely,  that  fibrous  tumors  of  the 
uterus  are  of  slow  growth,  of  low  vitality,  and  not  usually  reproduced 
from  their  capsule,  are  corroborated  by  observation.  The  source  of 
their  nutrition,  or  their  vascular  supply,  is  diffuse,  coming  through 
many  small  channels  at  various  points  in  their  periphery,  and  not,  as 
in  the  ovarian  tumors,  from  one  great  artery.  Such  a  supply  is  the 
cause  of  a  somewhat  definite  period  of  vitality.  It  is  not  capable  of 
maintaining  the  growth  to  an  indefinite  degree,  and  a  disturbance  of 
its  nutrition  may  easily  occur.  Thus,  after  they  attain  a  certain 
magnitude,  they  are  likely  to  stop  growing,  and  in  many  instances 
they  degenerate  into  a  lower  form  of  tissue,  resembling  cartilage,  or 
even  to  descend  still  lower  in  the  scale  of  vitality,  and  be  partially 
changed  into  a  cretaceous  deposit.     Again,  their  low  vitality  subjects 


NATUEE   OF   FIBROUS   TUMORS.  613 

them  to  the  process  of  inflammation  or  eremacausis.  Inflammation, 
resulting  in  gangrenous  disintegration,  is  one  of  the  accidents  that 
sometimes  brings  about  their  discharge  and  cure.  At  other  times  it 
occasions  the  death  of  the  patient  during  the  complicated  consequences 
thus  arising.  I  have  witnessed  both  of  these  terminations.  The 
fibrous  tumor  of  the  uterus  is  frequently  multiple. 

The  jjosition  occupied  by  the  growth  is  accompanied  by  a  number 
of  important  effects.  When  situated  in  the  centre  of  the  wall — intra- 
mural— it  grows  more  rapidly  than  when  in  the  subserous  portion  of 
the  fibrous  structure,  but  probably  not  so  vigorously  as  when  nearer 
the  mucous  membrane,  or  when  it  belongs  to  the  submucous  variety. 
In  fact,  it  will  generally  be  found  that  the  nearer  the  peritoneum  the 
nucleus  of  origin,  the  more  slowly  will  the  tumor  increase  in  size. 
We  also  find  that  the  intramural  and  submucous  varieties  cause  the 
uterus  to  grow  and  become  vascular  with  much  greater  certainty  than 
the  subserous.  Indeed,  we  often  find  very  large  subserous  tumor^ 
growing  from  a  uterus  of  comparatively  small  dimensions.  The 
tumor  may  be  not  less  than  ten  times  the  size  of  the  organ  to  the  fun- 
dus of  which  it  is  attached.  If  a  tumor  of  this  size  were  developed  in 
the  centre  of  the  wall  of  the  body  of  the  uterus,  the  depth  of  the  cavity 
would  be  not  less  than  six  inches.  While  the  uterus  in  such  cases  is 
more  than  ordinarily  vascular,  it  is  not  so  much  so  as  it  would  have 
been  if  the  tumor  had  belonged  to  the  intramural  variety.  Of  course 
-the  polypus,  or  submucous  tumor,  develops  the  uterus  with  more 
uniformity  than  the  intramural  variety.  The  uterus,  in  the  cavity  of 
which  there  is  a  polypus,  grows  with  nearl}^  the  same  symmetry  as  if 
pregnant. 

It  logically  follows  from  these  facts  that  the  submucous  and  intra- 
mural varieties  are  the  most  mischievous,  as  the  more  rapidly  the 
uterus  groAvs,  the  more  certainly  will  it  do  mischief  by  pressure ;  and 
the  more  vascular  the  uterus  becomes,  the  more  hemorrhage  will 
occur.  And  we  find  from  observation  that  these  inferences  are  cor- 
rect. 

Again  we  find  that  developed  in  certain  zones  of  the  organ  their 
behavior  and  effects  are  different.  Fibrous  tumors  comparatively 
do  not  often  originate  in  the  cervical  portion  of  the  organ,  and  when 
they  do  their  growth  is  not  very  rapid,  nor  do  they  cause  the  uterus 
to  become  very  large.  In  the  corj)oral  zone  they  grow  most  rapidly, 
cause  the  uterus  to  enlarge  faster,  and  do  more  mischief.  Lastly,  in 
the  fundus  their  activity  of  growth  is  less  rapid,  and  produce  less 
morbid  changes  upon  the  organ. 

In  examining  uteri  containing  fibrous  tumors,  which  have  fallen 
under  my  observation,  I  have  noticed  that  the  character,  as  well  as 
the  degree  of  development,  has  varied  quite  considerably. 

The  growth  of  the  fibrous  structure  of  the  uterus  is  not  exactly  the 


614  TUMOES  OF  THE  UTERUS. 

same  in  character  and  degree  as  in  pregnancy.  The  fibres  are  cer- 
tainly enlarged,  and  they  become  muscular,  but  in  very  few  localities 
do  they  attain  to  the  same  perfection  as  in  pregnancy. 

In  the  subserous  variety  they  do  not  anywhere  attain  to  the  per- 
fection of  pregnancy,  and  are  usually  quite  rudimentary  in  their 
character.  Nor  do  they  possess  much  contractile  power.  In  the  in- 
tramural tumors  the  fibres  surrounding  the  grow^th  attain  much 
greater  dimensions,  and  acquire  great  power.  Seldom,  if  ever,  how- 
ever, do  they  assume  all  the  qualities  of  the  fibres  in  the  gravid  uterus 
at  term.  In  these  cases  the  fibres  in  the  opposite  wall  do  not  keep 
pace  with  those  surrounding  the  tumor.  In  the  submucous  variety 
the  fibres  external  to  the  tumor  in  the  same  side  in  which  they  origi- 
nate are  largel}^  developed,  while  those  between  the  tumor  and  mu- 
cous membrane  attain  considerable  length,  but  are  attenuated,  and 
lack  strength.  This  is  one  reason  why  they  are  pushed  into  the  cavity 
of  the  uterus. 

When  the  tumor  is  polypoid,  and  occupies  the  cavity  of  the  uterus, 
especially  if  it  comes  from  the  body  near  the  fundus,  filling  up  and 
distending  the  cavity  of  the  body  in  every  direction,  it  causes  great 
uniformity  of  development  of  the  fibres.  The  fibres  all  around  grow 
more  as  they  do  in  the  pregnant  uterus,  attain  great  power,  and  usually 
expel  the  growth  into  the  vagina. 

Very  nearly  the  same  statements  may  be  made  in  reference  to  the 
growth  of  the  vascular  system  in  the  diff'erent  varieties  of  tumors. 
The  vessels  are  more  enlarged  on  the  side  occupied  by  the  tumor  in 
the  intramural  and  subserous  than  on  the  unoccupied  side.  They  are 
more  generally  enlarged  in  the  intrauterine  polypus. 

It  may  be  further  stated  that  a  single  tumor  grows  more  rapidly, 
causes  greater  vascularity  in  the  uterus,  and  brings  about  greater 
hypertrophy  of  the  fibres  of  the  uterus  than  the  multinuclear  form. 
Indeed,  were  numerous  points  of  growth  to  commence  at  the  same 
time,  although  great  bulk  may  be  attained,  the  bulk  consists  in  the 
morbid  deposits  more  than  in  the  growth  of  the  physiological  struc- 
ture of  the  uterus.  This  is  so  markedly  the  case  that  after  a  certain 
time  this  kind  of  tumor  stops  growing  for  the  want  of  vascular  sup- 
ply, and  becomes  transformed  into  a  dense  tissue  of  a  vitality  far  below 
that  in  the  single  tumor.  It  sometimes  becomes  a  true  fibroid  degen- 
eration of  the  whole  uterus,  in  which  it  would  be  hard  to  trace  any  of 
the  anatomical  elements  peculiar  to  that  organ. 

Sym'pto'ms. 

From  this  exposition  of  the  growth  and  effects  of  tumors  upon  the 
surrounding  structures,  it  will  be  readily  inferred  that  the  symptoms 
observed  in  connection  wath  fibrous   tumors  of  the  uterus  are  not 


SYMPTOMS.  »  615 

the  same,  and  must  vary  greatly  in  the  different  varieties.  The  most 
frequent  symptom  is  hemorrhage,  either  at  the  time  of  menstruation 
or  during  the  intervals.  In  the  early  periods  of  the  growth  the  pa- 
tient will  observe  profuseness  in  the  menstrual  flow,  and  some  cases 
occur  in  which  this  is  the  only  time  when  there  is  loss  of  blood,  but 
in  very  many  instances  the  losses  take  place  at  irregular  intervals, 
and  sometimes  the  discharge  is  so  irregular  that  the  patient  will  lose 
her  knowledge  of  the  time  when  she  ought  to  be  unwell.  In  quite  a 
large  proportion  of  cases  there  is  no  deviation  from  the  ordinary  habit 
of  menstruation.     The  patient  is  regular. 

The  variations  of  this  hemorrhagic  symptom  conform,  in  general, 
to  well-known  conditions,  and  we  may  expect  to  find  the  hemorrhage 
more  profuse  the  nearer  the  tumor  is  situated  to  the  mucous  mem- 
brane. In  hemorrhagic  cases  we  shall  also  find  that  the  size  of  the 
tumor  has  much  to  do  with  the  flow.  The  larger  the  tumor,  other 
things  being  equal,  the  greater  the  hemorrhage.  Large  submucous 
tumors  will,  therefore,  cause  more  profuse  hemorrhage  than  any  other 
sort.  In  estimating  the  value  of  the  rule  in  the  correspondence  of 
these  conditions,  we  must  remember  the  frequent  coexistence  of  small 
submucous  with  large  subserous  tumors,  and  that,  as  there  are  excep- 
tions to  all  rules,  we  may  sometimes  have  profuse  hemorrhage  in  sub- 
serous, and  small  losses  in  submucous  tumors.  The  latter  exception, 
however,  is  very  rare. 

'  Leucorrhoea,  consisting  of  thick,  tenacious  mucus,  from  the  cer- 
vical cavity,  is  perhaps  the  next  most  frequent  symptom,  and  it  is 
generally  governed  by  the  same  rules  with  respect  to  frequency  and 
profuseness  as  metrorrhagia,  being  greater  in  quantity  in  submucous 
than  subserous  tumors. 

Watery  discharges  from  the  uterus  are  also  a  common  and  signifi- 
cant symptom.  They  occur  more  frequently  just  after,  and  appear 
to  be  supplemental  to,  the  hemorrhages ;  and  I  must  observe  with 
reference  to  them,  also,  that  they  are  usually  more  profuse  in  sub- 
mucous tumors.  It  will  be  observed  that  all  the  discharges — hem- 
orrhagic, leucorrhoeal,  and  watery — show  themselves  under  the  same 
circumstances,  and  there  is  a  very  good  reason  for  this,  which  I  men- 
tion in  passing.  The  cases  in  which  the  tumors  are  so  situated  as  to 
greatly  increase  the  vascularity  of  the  uterus,  are  also  the  cases  in 
which  these  discharges  are  more  profuse. 

Dysmenorrhoea  is  not  so  commonly  met  with  as  the  three  symp- 
toms already  mentioned.  When  it  does  occur  it  is  of  the  obstructive 
variety.  It  is  manifested  by  cramping  pain  recurring  at  intervals. 
We  may  account  for  its  assuming  this  phase  by  the  fact  that  the  tumor 
encroaches  upon  the  cavity  of  the  uterus  and  renders  it  tortuous,  and 
in  some  cases  occludes  it  by  forcibly  pressing  the  sides  together.  The 
blood  is  accumulated  above  these  obstructed  places,  and  the  pains 


616  TFMOES  OF  THE  UTEEUS. 

are  caused  by  the  efforts  of  the  uterus  to  expel  the  blood  thus  im- 
prisoned. 

The  subserous  tumor  is  the  only  kind  that  may  not  occasionally 
cause  dysmenorrhoea.  It  is  probably  more  frequently  present  where 
there  is  a  number  of  nuclei  of  development,  some  of  them  being  sub- 
mucous. 

Among  other  symptoms,  I  wish  particularly  to  call  attention  to 
that  oi pressure.  It  begins  very  early  in  the  progress  of  these  growths, 
and  is  quite  often  noticed.  The  first  evidence  of  pressure  is  suffering 
in  the  pelvis.  When  the  tumor  first  becomes  enlarged,  the  uterus 
presses  upon  the  perineum,  and  this  pressure  causes  a  feeling  of  un- 
usual weight  in  that  region.  This  "  bearing-down  sensation  "  may 
increase  until,  finally,  the  uterus  and  vagina  may  protrude  through 
the  vulva ;  the  womb  may  also  fall  backwards  upon  the  rectum  and 
produce  tenesmus  or  other  uneasiness  in  that  organ ;  and  not  unusu- 
ally hemorrhoids  are  thus  developed  with  their  attendant  symptoms. 
Should  anteversion  occur,  the  bladder  will  suffer  from  the  pressure 
in  the  various  forms  of  dysuria,  and  even  inflammation  in  that  viscus. 
When  the  tumor  is  located  in  the  posterior  wall,  the  uterus  is  retro- 
verted  ;  when  in  the  anterior,  it  is  anteverted.  When  the  organ  is 
enlarged  equally  in  all  directions,  it  will  be  prolapsed.  As  it  enlarges 
so  as  to  fill  up  the  pelvis,  the  pelvic  veins  are  sometimes  so  pressed 
upon  as  to  retard  their  circulation,  and  there  may  arise  varicosity  in 
the  legs,  anus,  vulva,  and  surrounding  parts.  The  nerves  suffer  from 
the  pressure  in  such  a  way  as  often  to  manifest  sciatica,  and  crural 
and  vulvar  neuralgia. 

When  the  tumor  is  large  enough  to  rise  out  of  the  pelvis,  it  may 
cause  pressure  upon  the  abdominal  viscera,  and  by  its  bulk,  hardness, 
and  irregular  shape  give  rise  to  great  inconvenience  from  distension 
of  the  abdominal  cavity,  producing  more  suffering  than  the  same  dis- 
tension from  most  other  causes. 

Several  important  complications  are  likely  to  result  from  pressure, 
such  as  inflammation  of  the  pelvic  viscera,  cystitis,  rectitis,  cellulitis, 
and  local  peritonitis.  I  need  not  stop  to  give  the  symptoms  of  these 
complications, as  they  are  the  same  as  when  arising  from  other  causes. 
The  pelvic  inflammation  sometimes  extends  to  the  veins  passing 
through  the  cavity,  and  gives  rise  to  phlegmasia  alba  dolens. 

Abdominal  inflammations  also  complicate  these  cases,  some  forms 
of  peritonitis  especially.  A  moderate  peritoneal  inflammation  may 
result  in  serous  effusion,  and  the  ascites  sometimes  gives  rise  to  more 
trouble  than  the  tumor,  being  in  some  cases  the  immediate  cause  of 
the  fatal  result. 

The  consideration  of  the  effects  caused  by  pressure  exerted  by  these 
tumors  leads  me  to  the  subject  of  their  progress  and  development. 

It  may  be  said  of  them,  in  a  general  way,  that  their  growth  is  slow. 


DIAGNOSIS.  617 

This  is  especially  so  as  compared  with  most  other  growths.  In  very- 
many  cases  it  requires  years  for  them  to  attain  a  magnitude  sufficient 
to  endanger  the  patient's  life.  Indeed,  some  patients  carry  them 
through  a  long  life  without  experiencing  more  than  a  slight  incon- 
venience. Occasionally  exceptional  instances  occur,  however,  in  which 
the  growth  is  rapid  and  very  destructive. 

The  conditions  which  promote  their  growth  are  now  pretty  well 
understood,  especially  the  general  proposition :  that  the  more  vascu- 
lar the  uterus  becomes  from  any  cause  the  more  rapid  their  growth. 
The  converse  of  this  statement  becomes  a  necessary  corollary. 

They  grow  rapidly  during  pregnancy.  During  the  period  of  life 
in  which  the  menstrual  discharges  occur  in  a  normal  way,  the  tumor 
grows  more  rapidly  than  after  the  menopause.  The  submucous  in- 
crease in  size  with  more  rapidity  than  the  subserous,  and  the  tumor 
centrally  located  in  the  uterine  wall  generally  requires  for  its  devel- 
opment a  period  of  time  which  may  be  regarded  as  a  mean  between 
the  other  two.  The  multiple  ones  advance  more  sloAvly  than  the 
single  tumors.  There  is  one  circumstance  which  may  add  greatly  to 
the  vitality  of  any  of  these  growths,  and  consequently  cause  them  to 
grow  with  great  energy.  I  allude  to  adhesions  to  the  visceral  or 
parietal  peritoneum.  When  extensive  adhesions  occur,  the  vessel  of 
the  adherent  surface  penetrates  the  uterine  tissue  and  greatly  increases 
its  vascularity.  This  is  so  remarkably  the  case  in  rare  instances,  that 
-the  peritoneal  surface  of  the  tumor  becomes  reticulated  with  large 
vessels.  The  growths  thus  usually  become  very  formidable.  Occa- 
sionally, tumors  that  have  grown  so  slowly  as  to  seem  stationery  in 
this  respect,  suddenly  start  up,  and  their  behavior  is  entirely  changed. 
We  see  this  in  subserous  tumors  in  a  remarkable  manner.  It  is 
hardly  necessary  for  me  to  remind  the  reader  that  this  change  is 
generally  preceded  by  inflammation,  and  that  this  is  the  cause  of 
adhesions. 

When  the  tumors,  as  sometimes  happens,  undergo  interstitial  de- 
generation in  such  a  manner  as  to  cause  cavities  in  their  substance, 
they  grow  rapidly  by  an  accumulation  of  fluid  in  these  hollow  spaces. 
This  change  constitutes  a  new  variety,  which  is  called  fibro-cystic. 
They  often  become  very  large,  grow  very  rapidly,  and  are  mistaken 
for  ovarian  tumors.  Some  of  our  most  expert  specialists  have  been 
betrayed  into  their  removal  under  this  misapprehension,  and  have 
sometimes  been  made  aware  of  their  mistake  only  after  a  careful 
examination  subsequent  to  their  extirpation. 

Diagnosis. 

We  learn,  after  much  observation,  that  the  history  and  symptoms, 
although  very  important  items  in  the  diagnosis,  are  not  sufficient  to 
establish  it,  hence  we  are  obliged  to  resort  to  physical  examination. 


618  TUMOES   OF   THE   UTERUS. 

Another  observation  may  be  made  in  this  connection ;  the  greatest 
difficulties  in  forming  a  correct  diagnosis  will  be  experienced  in 
tumors  of  each  extreme  in  size.  The  medium-sized  tumors  may  be 
diagnosed  without  much  trouble.  In  cases  of  small-sized  tumors  we 
cannot  always  determine  without  much  care  whether  the  enlargement 
of  the  uterus  is  due  to  a  tumor  or  some  other  cause.  In  such  cases 
the  depth  of  the  uterus  should  be  measured  by  the  sound.  While 
the  sound  is  in  the  uterus,  and  that  organ  held  in  its  normal  posi- 
tion, the  finger  is  to  be  passed  as  high  as  possible  into  the  rectum, 
and  the  posterior  wall  thoroughly  explored.  If  there  is  a  tumor  in 
that  part  it  will  be  found  thickened  and  nodulated.  Should  this  not 
be  the  case  a  male  catheter  should  be  introduced  into  the  bladder,  and 
the  anterior  wall  of  the  uterus  carefully  surveyed.  If  the  symptoms 
are  sufficiently  grave  to  excite  apprehensions,  and  yet  leave  an  un- 
certainty, the  finger  may  be  passed  into  the  bladder  instead  of  the 
catheter ;  otherwise  it  should  not  be  used. 

To  ascertain  the  existence  of  a  small  intrauterine  or  submucous 
growth  the  cervix  should  be  dilated  with  sea-tangle,  or  compressed 
sponge-tent,  until  the  finger  can  be  passed  into  the  cavity  of  the  body, 
when  there  will  be  no  difficulty  in  finding  the  tumor.  None  of  these 
proceedings  are  justifiable,  if  there  is  tenderness  or  other  signs  of 
general  inflammation  of  the  uterus. 

It  is  more  frequently  the  case  that  the  tumor  is  evident,  and  then 
the  object  is  to  ascertain  if  it  is  uterine.  To  determine  this  question 
it  is  necessary  to  discover  its  attachments.  This  may  be  done  placing 
one  finger  on  the  mouth  of  the  uterus,  and  another  in  the  rectum  to 
move  the  tumor.  If  it  is  attached  to  the  uterus  they  will  move 
together.  We  should  be  careful,  in  making  this  kind  of  an  examina- 
tion, to  make  the  movements  vary  in  direction,  if  possible,  the  tumor 
should  be  moved  from  the  uterus,  or  upward,  or  downward.  The 
tumor  ought  to  carry  the  uterus  with  it  when  moved  in  any  direc- 
tion. If  the  sound  is  passed  into  the  uterus,  and  the  tumor  moved 
afterwards,  the  instrument,  as  may  be  seen,  will  very  plainly  indicate 
the  movement  of  the  organ.  The  cavity  will  also  be  increased  in 
length.  When  a  tumor  is  large  enough  to  be  felt  above  the  pubis  the 
attachment  will  be  more  easily  made  out  by  moving  it  with  the 
hands  pressed  upon  it  from  above,  Avhile  the  sound  is  in  the  cavity,  or 
the  finger  on  the  cervix. 

The  second  most  important  diagnostic  indication  is  the  firmness  of 
the  tumor.  The  fibrous  tumor  is  usually  hard  and  not  elastic.  An- 
other almost  essential  circumstance  has  just  been  alluded  to,  viz.,  the 
increased  depth  of  the  uterine  cavity.  The  history  of  the  case  will 
generally  enable  us  to  decide,  whether  the  tumor  under  examination 
is  one  caused  by  inflammation  or  not;  the  inflammatory  tumor,  more- 
over, is   seldom   movable.     A  htematocele   is   behind   the   uterus,  is 


PROGNOSIS.  619 

elastic,  and  has  the  shape  of  the  cul-de-sac,  instead  of  being  glob- 
ular. 

When  the  tumor  is  large  enough  to  fill  up  the  abdominal  cavity, 
and  become  immovable  in  consequence  of  its  bulk,  it  is  usually  but 
not  always  elastic.  If  so,  it  has  become  fibro-cystic.  We  cannot 
always  determine  the  relation  of  these  tumors  to  the  uterus  by  the 
methods  I  have  described.  Often  we  are  unable  to  introduce  a  sound 
into  the  uterine  cavity,  in  consequence  of  its  tortuous  direction,  and 
the  diagnosis  becomes  extremely  difficult.  These  are  the  tumors,  as 
I  have  before  said,  that  have  been  mistaken  for  and  removed  as 
ovarian  tumors.  Probably  the  only  positive  way  of  clearing  up  the 
diagnosis,  is  to  draw  off  some  of  the  fluid  with  a  trocar,  or  aspirator, 
and  make  its  character  the  test.  Dr.  Washington  L.  Atlee,  of  Phila- 
delphia, in  his  admirable  work  on  the  Diagnosis  of  Ovarian  Tumors, 
has  furnished  us  with  a  description  of  the  fluid  derived  from  this 
kind  of  fibrous  tumor,  that  is  every  way  correct.  The  fluid  does  not 
run  out  of  the  canula  of  the  trocar  with  the  facility  with  which  the 
ovarian  fluid  is  evacuated,  and  often  when  it  is  received  in  a  vessel, 
and  becomes  somewhat  cool,  it  coagulates,  and  like  blood  separates 
into  clot  and  serum.  When  examined  by  the  microscope,  debris  of 
blood-corpuscles  and  fibrillffi  of  fibrin  are  the  characteristic  substances 
found.  One  other  circumstance  I  have  failed  to  call  attention  to  is, 
that  fluctuation  observed  upon  percussion  is  less  decided  than  in 
oTarian  tumors.  If  the  tumor  is  large  enough  to  distend  the  abdo- 
men, it  may  be  complicated  with  peritoneal  dropsy.  This  condition 
also  renders  the  diagnosis  obscure.  Tapping  will  generally  enable  us 
to  arrive  at  correct  conclusions.  After  the  ascitic  fluid  has  been  re- 
moved, an  examination  of  the  tumor  will  enable  us  to  establish  its 
relations  to  the  uterus,  as  well  as  determine  its  density  and  shape. 

The  fluid  in  these  cases  should  be  submitted  to  microscopic  exam- 
ination with  a  view  to  ascertain  wdiether  it  came  from  an  ovarian  cyst 
or  the  peritoneal  cavity. 

Prognosis. 

There  are  several  considerations  which  render  the  general  prog- 
nosis favorable  as  compared  with  other  tumors  for  which  they  may 
be  mistaken. 

They  occur  generally  in  persons  who  have  made  a  near  approach 
to  the  menopause,  and  generally  they  cease  growing  after  this  condi- 
tion is  passed.  They  grow  slowly,  and  may  not  be  expected  to  arrive 
at  dimensions  sufficiently  great  to  cause  fatal  consequences  for  many 
years,  if  ever.  They  often  stop  growing  without  any  discoverable 
reason ;  they  sometimes  undergo  degeneration  into  inert  masses, 
which  remain  as  mere  inconvenient  bodies.-  Nature  sometimes  gets 
rid  of  them  by  expulsion,  or  they  may  be  protruded  from  the  uterus 


620  TUMORS  OF  THE  UTERUS. 

into  the  vagina,  within  reach  of  surgical  measures.  Lastly,  many  of 
them  disappear  under  judicious  medical  treatment,  or  all  the  threat- 
ening symptoms  attendant  upon  them  may  be  removed  by  such 
means. 

Almost  none  of  these  conditions  obtain  in  ovarian  tumors  and  very 
few  in  any  others  found  in  the  same  locality.  These  considerations 
will  establish  the  conclusion  that  the  general  prognosis  is  favorable. 

The  circumstances  which  in  individual  cases  form  an  unfavorable 
prognosis  are:  the  youth  of  the  patient,  as  they  usually  grow  more 
rapidly  in  young  persons ;  the  rapid  growth  of  the  tumor ;  hemor- 
rhagic symptoms;  unfavorable  complications,  as  peritoneal  dropsy, 
inflammation  in  the  pelvis  or  abdomen,  pressure  upon  the  pelvic 
organs,  nerves,  or  vessels;  inflammation  of  the  tumor,  impaction  in 
the  pelvis,  uraemia,  ansemia,  pregnancy,  ovarian  tumor,  etc.  The 
fibro-cystic  variety  possesses  several  elements  of  danger ;  its  rapidity 
of  growth  being  the  cause  of  several  others,  as  pressure,  impaction, 
dropsy,  etc. 

The  complications  of  pregnancy  and  labor  with  fibrous  tumors  of 
the  uterus  is  one  of  sufficient  importance  to  demand  special  consid- 
eration, especially  as  we  may  be  obliged  to  determine  a  course  of 
action  when  the  emergency  leaves  no  time  for  research.  The  simjjle 
coexistence  of  a  fibrous  tumor  with  pregnancy  is  not  sufficient  reason 
for  interference,  and  I  am  persuaded  from  personal  observation  that 
there  are  but  few  cases  which  call  for  any  interference  whatever. 

I  do  not  wish  to  be  dogmatic,  but  I  desire  to  make  a  few  definite 
statements  of  what  I  regard  as  facts.  Pregnancy  takes  place  more 
frequently  when  the  tumor  is  situated  in  the  central  zone  of  the 
uterus  and  remote  from  the  mucous  membrane ;  but  it  will  not  occur 
if  the  tumor  belongs  to  the  submucous  variety,  although  it  is  in  the 
middle,  or  even  in  any  part  of  the  uterus  except  the  cervical  portion 
of  the  inferior  zone.  I  have  already  intimated  that  there  are  very 
few  large  tumors  developed  in  the  inferior  or  cervical  zone  compared 
with  those  that  arise  from  the  central  corporeal  and  superior  or  fundal 
zone,  and  that  such  as  these  are  usually  developed  in  the  submucous 
tissue  and  are  generally  pendulous — these  do  not  appear  to  interfere 
very  much  with  pregnancy.  From  what  I  can  learn  and  have  ob- 
served pregnancy  seldom,  if  ever,  takes  place  when  the  tumor,  being 
of  more  than  moderate  size  or  situated  near  the  mucous  membrane, 
is  located  in  the  fundus  or  upper  portion  of  the  superior  zone.  In 
general  the  larger  the  tumor  the  less  likelihood  of  pregnancy,  and  if 
it  does  occur  the  impossibility  of  normal  uterine  development  leads 
to  abortion. 

The  dangers  to  be  apprehended  arise  usually  at  the  time  of  labor 
and  consist:  1,  In  the  obstruction  to  delivery  caused  by  the  tumor 
blocking  up  the  pelvis ;  2,  in  the  incomplete  contraction  after  delivery 


PROGNOSIS.  621 

failing  to  close  up  the  placental  vessels,  and  thus  causing  grave,  if  not 
fatal,  hemorrhage.  Tumors  situated  in  the  superior  zone,  the  middle 
zone,  or  the  upper  portion  of  the  inferior  zone  will  offer  little  obstruc- 
tion, because  the  head  will  have  passed  them  above  the  pelvic  brim. 
This  leaves  but  a  limited  number  and  those  small  in  size  that  are 
crowded  down  into  the  pelvis  b}'  the  side  of  or  before  the  fetal  head ; 
they  are  the  submucous  or  polypoid  variety  situated  in  the  cervical 
portion  of  the  inferior  zone.  Such  tumors  are  generally  pressed  en- 
tirely out  of  the  vulva  and  permit  the  head  to  pass  out  after  them.  I 
may  mention,  in  passing,  that  they  may  sometimes  be  detached  from 
their  base  by  the  pressure  of  the  head ;  or,  remaining  intact,  may  be 
retracted  within  the  pelvis  after  the  labor  is  over. 

The  second  danger  is,  I  think,  very  much  overrated.  The  fact  of  the 
fibrous  tissue  of  the  uterus  having  been  developed  sufficiently  to  per- 
mit of  the  completion  of  gestation  is  an  evidence  that  it  is  sufficiently 
powerful  to  contract  fully,  and  one  single  case  recently  published  by 
Dr.  Chadwick,  of  Boston,  in  which  the  placenta  was  implanted  on  the 
uterus  over  the  seat  of  the  tumor,  and  in  which  hemorrhage  did  not 
prove  serious  after  delivery,  goes  far  to  prove  that  great  danger  from 
this  cause  is  not  likely  to  occur.  In  no  case  of  labor  associated  with 
a  tumor  which  has  come  under  my  own  observation  has  hemorrhage 
been  a  grave  symptom. 

It  is  fair,  I  think,  in  the  light  of  our  present  knowledge,  to  infer  that 
it  is  seldom  necessary  to  interrupt  pregnancy  when  complicated  with 
fibrous  tumors  of  the  uterus,  as,  in  the  nature  of  things,  gestation  will 
not  continue  unless  there  is  sufficient  integrity  of  uterine  tissue  to  per- 
mit ample  development.  At  the  time  of  labor  the  indication  for 
operative  procedure  will  appear  in  the  want  of  progress,  and  then  the 
obstacles  may  be  surmounted  by  turning,  or  forceps,  if  the  propulsive 
powers  of  the  uterus  are  not  sufficient.  Common  prudence  will  incite 
to  vigilance  in  preventing  hemorrhage  in  these  as  in  other  complicated 
cases  of  labor.  It  will  be  observed  that  while  I  cannot  ignore  the  im- 
portance of  watching  these  cases  attentively,  I  am  far  from  consider- 
ing them  as  necessarily  very  dangerous. 

Another  question  of  great  importance  is,  what  effect  does  pregnancy 
and  labor  have  upon  the  tumor? 

In  a  minority  of  cases  none  whatever.  The  tumor  remains  the  same 
after  the  pregnancy  has  terminated  as  before.  But  in  the  majority  of 
cases  it  is  far  otherwise.  In  three  instances  of  this  nature,  which  have 
come  under  my  own  observation,  the  tumors  have  disappeared ;  and 
the  manner  of  their  disappearance  is  worthy  of  remark.  In  one  in- 
stance, occurring  two  years  since,  the  tumor  was  located  in  the  posterior 
wall  of  the  uterus,  apparently  in  the  central  portion  of  it,  and  occupied 
the  middle  zone.     The  pregnancy  proceeded  without  accident,  and  the 


622  TUMORS  OF  THE  UTERUS. 

patient  was  delivered  at  term  of  a  dead  foetus,  which,  judging  from 
appearance,  must  have  been  dead  three  days  before  labor  came  on. 
Moreover,  according  to  the  calculation  of  the  mother,  the  first  pains 
did  not  appear  until  two  weeks  after  the  expiration  of  two  hundred 
and  eighty  days.  The  head  was  arrested  at  the  superior  strait  and 
impinged  upon  the  symphysis  pubis,  but  was  easily  moved  from  this 
position.  I  did  not  see  the  patient  until  four  hours  after  the  membranes 
had  been  ruptured.  At  this  time  the  presenting  part  did  not  advance, 
and,  after  consultation  with  the  attending  physician.  Dr.  John  F.  Wil- 
liams, of  this  city,  it  was  considered  best  to  interfere.  I  introduced, 
my  hand,  seized  one  of  the  feet  and  brought  it  down.  There  was  no 
great  difiiculty  in  the  turning  or  delivery.  The  placenta  came  away 
in  a  few  minutes  with  a  very  slight  loss  of  blood.  I  had  first  seen 
this  patient  when  gestation  had  advanced  to  the  end  of  the  third 
month.  At  this  time  I  believed  the  tumor  to  be  about  the  size  of  a 
fetal  head  at  term.  It  was  extremely  hard,  and  presented  two  distinct 
nodules.  At  this  consultation  I  ad^dsed  non-interference.  I  saw  her 
again  several  times  during  her  pregnancy.  She  was  a  primipara. 
After  the  delivery  of  the  placenta  I  felt  curious  to  know  what  effect 
the  pregnancy  had  upon  the  size  and  consistency  of  the  tumor.  In 
order  to  determine  these  points  I  introduced  one  hand  into  the  uterus, 
and  with  the  other  manipulated  above  the  symphysis.  In  this  way  I 
could  fix  and  handle  the  tumor  with  facility.  It  then  seemed  to  be 
about  the  size  of  the  fetal  head  and  very  hard.  The  division  between 
the  firmly  contracted  uterus  and  the  tumor  was  marked  by  a  well-de- 
fined sulcus,  traceable  by  the  hand,  above  the  pelvic  brim.  The 
tumor  seemed  harder  than  the  contracted  uterus.  I  had  the  oppor- 
tunity of  seeing  and  examining  this  patient  frequently  during  the 
year  succeeding  her  accouchement.  The  tumor  was  decidedly  less 
in  three  months,  and  continued  to  disappear.  At  the  expiration  of 
twelve  months  it  was  no  longer  jDerceptible,  and  the  cavity  of  the  uterus 
measured  but  two  inches  and  a  quarter.  The  patient  now  menstruates 
normally  in  every  respect. 

The  careful  observation  of  this  case  convinced  me  that  the  tumor 
had  net  grown  materially  larger  nor  become  softened  during  gesta- 
tion, and  led  me  to  believe  that  the  process  of  absorption  began  and 
proceeded  with  the  subsequent  involution  of  the  uterus.  What  effects 
may  have  been  wrought  upon  its  tissues  by  the  contractions  during 
labor  I  cannot,  of  course,  determine  ;  but  the  gradual  disappearance  of 
the  tumor  and  the  non-appearance  of  inflammatory  or  other  urgent 
symptoms  plainly  indicate  that  the  contractions  of  the  uterus  during 
labor  could  not  have  produced  any  very  violent  effects  upon  it.  It 
was  also  evident  that  the  tumor  was  absorbed  and  slowly  removed 
without  disturbing  the  good  health  of  the  patient. 


PEOGNOSTS.  623 

In  the  other  two  cases  I  verified  the  existence  of  fibrous  tumors 
before  pregnancy  took  place,  and  one  of  them  I  saw  again  after  a  lapse 
of  five  months,  but  was  not  present  at  the  time  of  parturition  of  either 
of  them,  nor  have  I  seen  them  subsequently.  I  have  been  assured, 
however,  by  letters  from  their  attending  physicians,  that  they  recog- 
nized the  tumor  after  labor,  and  that  they  both  disappeared  within  a 
year. 


CHAPTER    XXXIX. 

FIBROUS  TUMOES   OF  THE  UTERUS    {Continued). 

Treatment. 

The  treatment  of  fibrous  tumors  of  the  uterus  consists  largely  of 
the  means  calculated  to  relieve  such  symptoms  as  endanger  the  life 
of  the  patient  or  materially  affect  her  general  health.  When  these 
are  unavailing,  resort  is  had  to  measures  calculated  to  get  rid  of  the 
tumor.  Some  remedies  necessary  to  the  relief  of  symptoms  act  as 
very  powerful  curative  agents ;  hence,  while  it  is  convenient  to  speak 
of  the  treatment  of  symptoms  under  one  division  of  the  subject,  and 
the  methods  employed  for  radical  cure  under  another,  we  cannot,  in 
fact,  completely  separate  these  two  branches.  The  reader  will  not  be 
surprised,  therefore,  if  I  feel  myself  obliged  to  depart  from  this  arbi- 
trary method  of  presenting  my  subject. 

Hemorrhage  is  by  far  the  most  important  of  the  symptoms  con- 
nected with  these  growths,  because  it  is  at  the  same  time  the  most 
frequent  and  hazardous.  It  is  also  the  symptom  that  leads  to  most 
suffering  in  consequence  of  depriving  important  organs  of  the  blood 
necessary  to  support  them  in  their  functions.  Every  means,  there- 
fore, should  be  made  use  of  not  only  to  prevent  fatal  losses  but  also 
to  prevent  even  slight  hemorrhage.  In  the  outset,  therefore,  I  would 
insist  upon  watching  with  great  vigilance  to  prevent  any  unusual  loss 
of  blood.  It  will  be  understood  by  this  that  I  advise  not  to  tem- 
porize by  adopting  the  milder  and  less  efficient  measures  as  being 
sufficient  for  cases  not  likely  to  prove  fatal,  but  to  treat  all  hemor- 
rhage arising  from  this  cause  with  promptitude  and  energy.  Fortu- 
nately in  many  cases  we  can  anticipate  the  attacks  of  hemorrhage 
because  we  know  when  they  will  recur,  and  we  are  generally  able 
to  judge  of  their  probable  severity.  To  discharge  our  duty  in  this 
respect  effectually,  our  patient  should  be  properly  provided  with 
remedies  and  fully  instructed  how  to  use  them.  She  should  be  made 
to  understand  that  unusual  hemorrhage  at  the  menstrual  period  may 
be  checked  without  endangering  her  general  health.  Among  the 
remedies  are  dorsal  recumbency  with  the  hips  elevated,  cold  to  the 
hypogastric  region,  and  cold  to  the  dorsal  spine  and  sacrum,  which 
can  be  effected  by  means  of  a  rubber  pillow  filled  with  ice  water, 
ergot  and  some  form  of  tampon.  The  best  fluid  extract  of  ergot  in 
drachm  doses,  if  the  stomach  will  bear  it,  is  probably  the  most  effica- 
cious medicine,  but  the  fresh  drug  in  the  form  of  infusion  is  also  very 


TREATMENT.  625 

efficient.  Full  doses  should  be  given  every  half  hour  when  there  is 
much  loss,  until  some  effect  is  produced  upon  the  hemorrhage,  and 
then  continued  every  four  hours  as  long  as  necessary.  Compressed 
sponges  saturated  with  the  solution  of  alum  make  the  best  tampon 
for  the  patient  to  make  use  of.  These  may  be  made  and  kept  in 
readiness,  so  that  they  can  be  introduced  as  soon  as  they  are  found 
necessary.  The  patient  or  nurse  can  make  them  by  taking  a  fine 
sponge,  large  enough  to  fill  the  vagina,  passing  a  piece  of  strong  string 
through  the  centre  to  aid  in  its  removal,  and  then,  after  dipping  it  in 
the  solution,  well  winding  it  with  twine  from  one  end  to  the  other, 
compressing  it  into  as  small  a  space  as  possible.  The  twine  should 
so  compress  the  sponge  as  to  make  it  assume  an  elongated  form.  It 
should  then  be  laid  aside  and  permitted  to  dry.  Several  sponges 
should  be  thus  prepared  and  dried.  When  necessary  the  twine  may 
be  unwound  and  the  sponge  introduced.  Its  size  when  in  the  dry 
condition  will  allow  of  an  easy  passage  into  the  vagina,  where  the 
moisture  will  cause  it  to  expand,  thus  filling  up  and  sealing  the 
vagina  so  as  to  absolutely  check  the  discharges.  If  the  attending 
physician  is  present  he  may  tampon  the  vagina  with  pellets  of  cotton 
secured  by  thread  and  moistened  with  the  solution  of  iron,  as  recom- 
mended by  J.  Marion  Sims  and  others.  The  inconvenience  experienced 
from  this  ironized  plug  will  be  more  than  counterbalanced  by  the 
saving  of  blood.  This  form  of  tampon  has  the  additional  advantage 
of  being  antiseptic.  I  have  allowed  it  to  remain  for  three  days,  and 
upon  removing  it  satisfied  myself  that  there  was  no  decomposition  of 
the  blood  or  the  vaginal  secretions.  When  the  tampon  is  removed  it 
will  not  be  found  difficult  to  wash  out  all  the  granular  clots  caused 
by  its  presence.  It  may  be  repeated  as  often  as  necessary,  but  usually 
if  allowed  to  remain  forty-eight  hours  the  hemorrhage  will  not  return. 
It  may  be  said  that  for  small  losses  this  is  unnecessary,  but  I  think 
this  is  a  more  convenient  form  of  tampon  than  any  other  that  will 
answer  the  purpose.  In  dangerous  cases  no  one  will  question  the 
propriety  of  its  employment. 

Another  very  important  means  of  arresting  hemorrhage,  which  can 
be  used  by  the  physician  when  necessary,  is  the  introduction  of  a 
compressed  sponge  into  the  cervix  uteri  for  the  purpose  of  dilating  it. 
This  will  temporarily  act  as  a  tampon  and  stimulate  the  uterine  fibres 
to  contraction.  A  point  of  much  importance  in  the  use  of  the  tampon 
or  sponge,  is  the  avoidance  of  septicsemic  poison,  and  I  know  no 
medicine  so  efficacious  and  handy  as  the  preparation  of  iron  I  have 
mentioned. 

The  pressure  of  the  tumor  upon  the  pelvic  viscera  is  another  in- 
convenience which  calls  for  attention.  This  takes  place  usually  at  a 
time  when  the  tumor  has  acquired  a  size  sufficient  to  fill  that  cavity. 
Consequently  the   elevation   of  the  tumor  above  the  pelvis  is  the 

40 


626  FIBROUS    TUMORS    OF   THE    UTERUS. 

remedy.  This  may  be  done  sometimes  by  placing  the  patient  in  the 
knee-elbow  position  and  opening  the  vagina  by  two  fingers,  and  then 
pressing  the  growth  upwards.  The  powerful  influence  of  atmos- 
pheric pressure  called  to  our  aid,  by  the  position  and  opening  of  the 
vagina,  is  a  very  material  auxiliary  in  the  process  of  elevation.  If  this 
is  not  sufficient,  we  may  pass  the  fingers  into  the  rectum  and  elevate 
the  tumor.  I  once  succeeded  in  this  operation  by  using  an  ivory- 
headed  cane  in  the  rectum  when  the  fingers  failed  to  reach  high 
enough. 

Dysmenorrhoea  is  another  symptom  of  fibrous  tumors,  and  some- 
times a  very  distressing  one,  which  we  are  often  called  upon  to  re- 
lieve. It  depends,  no  doubt,  as  I  have  before  said,  on  the  imprison- 
ment of  blood  in  the  uterine  cavity,  in  consequence  of  the  tortuosity 
of  the  canal  causing  the  closure  of  some  part  of  it.  The  remedy  con- 
sists in  ^dilating  these  narrow  places.  I  know  of  nothing  so  well  cal- 
culated to  eff'ect  this  object  as  the  slippery  elm  tent.  A  tent  of  this 
material,  long  enough  to  reach  the  fundus  uteri,  and  of  sufficient  size, 
moistened  so  as  to  render  it  very  flexible,  may  be  passed  up  through 
these  tortuous  places  with  great  facility.  If  introduced  as  soon  as 
the  symptom  begins  to  manifest  itself,  and  allowed  to  remain  an  hour 
or  two,  the  relief  will  be  pretty  certain.  If  used  once  a  day,  for  four 
or  five  days  before  the  attack,  and  three  or  four  hours  at  a  time,  dys- 
menorrhoea may  be  generally  avoided. 

When  we  broach  the  question  of  the  permanent  cure  of  these  atfec- 
tions,  we  find  that  great  difference  of  opinion  exists  among  the  mem- 
bers of  the  profession  as  to  the  value  of  medicines.  One  part,  per- 
haps a  majority,  believe  that  no  medicine  has  any  direct  effect  upon 
them,  and  they  ignore  any  means  of  permanent  relief  but  surgical. 
There  is,  however,  a  respectable  number  of  medical  men  who  place 
great  reliance  upon  the  administration  of  certain  medicines,  and,  if  I 
am  not  mistaken,  recent  observation  has  added  greatly  to  their  num- 
ber. They  do  not,  however,  wholly  agree  as  to  the  therapeutic  pro- 
cesses that  should  be  instituted,  and  consequently  do  not  employ  the 
same  kind  of  medicines.  Some  gentlemen  have  more  confidence  in 
what  I  will  term  the  sorbefacient  process  of  treatment.  They  endeavor 
to  institute  measures  that  will  cause  the  absorbents  to  attack  and 
remove  the  neoplasm  in  the  same  way  that  tumefactions  caused  by 
effusions  are  removed.  This  they  do  by  friction,  pressure,  and  the 
administration  of  the  old-fashioned  sorbefacient  medicines.  The  most 
popular  among  these  are  the  iodides,  chlorides,  and  bromides  of  mer- 
cury, potassium,  sodium,  calcium,  and  ammonium.  Reports  may  be 
found  in  books  and  our  periodical  medical  literature  of  cures  by  sev- 
eral, if  not  all,  of  these  articles  and  their  combinations.  The  late  Dr. 
W.  L.  Atlee,  whose  experience  has  been  very  extensive,  had  great  con- 
fidence in  the  action' of  chloride  of  ammonium.     He  caused  it  to  be 


TREATMENT.  627 

administered  internally,  applied  externally,  and  used  as  vaginal  injec- 
tions. The  iodide  of  potassium  has  long  enjoyed  a  great  reputation 
in  causing  the  absorption  of  these  and  other  forms  of  tumors.  There 
is  no  professional  fairness  in  assuming  that  the  faith  in  these  remedies, 
derived  from  the  observation  of  their  effects,  or  the  promulgation  of 
cures  from  the  use  of  sorbefacient  measures,  are  fallacious.  Some  of 
the  men  arrayed  in  favor  of  the  opinion  that  cures  may  be  effected  by 
a  patient  and  long-continued  administration  of  some  one  of  the  arti- 
cles I  have  mentioned,  stand  high  as  men  of  honesty,  accuracy  of 
observation,  and  faithfulness  in  their  records ;  and  for  one  I  give  full 
credence  to  their  statements.  Yet  I  must  also  say  that  I  have  not 
witnessed  the  good  results  which  I  unhesitatingly  believe  others  have 
seen  from  the  sorbefacient  treatment  alone. 

Others  who  expect  much  from  medicinal  treatment  look  to  that 
class  of  medicines  which  causes  contraction  of  the  unstriped  muscular 
fibres  as  the  most  promising.  With  these  medicines  they  expect  to 
diminish  the  supply  of  blood  to  the  tumor,  by  causing  contraction  of 
the  arterioles  traversing  their  substance,  and  thus  disturbing  their  nu- 
trition to  such  a  degree  as  to  stop  their  growth,  lessen  or  destroy  their 
vitality,  and  so  render  them  subject  to  the  influence  of  the  absorbents, 
whereby  they  may  be  removed.  Some  of  the  more  energetic  of  these 
medicines,  as  ergot,  for  instance,  often  affect  these  growths  very 
promptly. 

I  shall  limit  my  remarks  upon  this  class  of  medicines  to  what  is 
known  of  the  effects  of  ergot. 

As  an  introduction  to  what  I  have  to  say  of  ergot  I  submit  the  fol- 
lowing propositions  :  1.  When  properly  administered,  ergot  frequently 
very  greatly  ameliorates  some  of  the  troublesome  and  even  dangerous 
symptoms  of  fibrous  tumors  of  the  uterus,  e.  g.,  hemorrhage  and  co- 
pious leucorrhoea.  2.  It  often  arrests  their  growth  and  checks  hemor- 
rhage. .3.  In  many  instances  it  causes  the  absorption  of  the  tumor, 
occasionally  without  giving  the  patient  any  inconvenience;  at  other 
times  the  removal  of  the  tumor  by  absorption  is  attended  by  painful 
contractions  and  tendernigss  of  the  uterus.  4.  By  inducing  uterine 
contraction  it  causes  the  expulsion  of  the  polypoid  variety.  5.  In  the 
same  way  it  causes  the  disruption  and  discharge  of  the  submucous 
tumor. 

There  are  many  cases  on  record  to  substantiate'  every  one  of  these 
propositions. 

From  what  I  consider  well-authenticated  sources,  including  the 
cases  under  my  own  observation  and  in  the  practice  of  mj^  friends 
and  neighbors,  I  have  collected  one  hundred  and  thirty-six  cases  of 
fibroid  tumors  treated  by  ergot.-  Of  these,  twenty-five  cases  were 
cured  without  giving  the  patient  any  inconvenience  from  painful  con- 
tractions.    In  forty-six  cases  the  tumors  were  diminished  in  size  and 


628  FIBROUS   TUMORS   OF   THE   UTERUS. 

the  hemorrhage  was  cured.  In  twenty-seven  others  the  hemorrhagic 
symptoms  were  relieved,  while  the  size  of  the  tumor  was  not  affected. 
In  eight  other  instances  the  tumors  were  broken  to  pieces  and  expelled 
piecemeal. 

At  the  risk  of  being  tedious  I  will  copy  the  summary  of  cases  and 
opinions  reported  to  me  and  given  in  my  address  on  Obstetrics  made 
before  the  American  Medical  Association  in  1875 : 

Cases. 

It  is  well  known  that  Professor  Hildebrandt,  in  a  communication 
to  the  twenty-fifth  number  of  the  Berliner  Wochenschrift,  as  early  as 
1871,  called  the  attention  of  the  profession  to  the  utility  of  ergotin  in 
the  treatment  of  fibrous  tumors  of  the  uterus.  While  administering 
it  by  hypodermic  injections  to  moderate  the  hemorrhages,  so  often  a 
troublesome  symptom  in  connection  with  these  growths,  he  was  struck 
with  the  decided  diminution  in  the  size  of  the  tumor.  A  continuation 
of  the  remedy  thus  administered  resulted  in  the  entire  disappearance 
of  one  of  them  in  fifteen  weeks.  In  eight  cases,  all  but  two  under- 
went great  improvement.  The  great  pain  caused  by  injection  ren- 
dered the  treatment  intolerable  to  one  of  these  two  patients.  In  the 
other  the  treatment  was  discontinued  on  account  of  ergotic  intoxica- 
tion. In  four  others,  the  tumors  were  greatly  diminished,  and  promised 
speedy  cures,  but  for  various  reasons  the  treatment  was  not  continued. 
One  tumor  of  huge  size,  reaching  above  the  umbilicus,  totally  disap- 
peared ;  while  another,  extending  to  the  ribs,  and  largely  distending 
the.  abdomen,  was  greatly  reduced.  The  debilitating  hemorrhages 
and  leucorrhoeal  discharges  were  promptly  relieved  in  six  of  them. 

In  the  American  Journal  of  Obstetrics  for  January,  1875,  Dr.  Hilde- 
brandt gives  a  synopsis  of  nineteen  more  cases  treated  by  him.  Two 
of  these  were  cured  ;  and  in  six  others  the  tumors  were  greatly  dimin- 
ished in  size,  and  the  hemorrhages  relieved.  In  eleven  of  these  cases 
all  the  disagreeable  symptoms  were  relieved,  but  the  size  of  the  tumor 
was  not  perceptibly  affected.  The  last  two  cases  reported  in  this 
series  of  nineteen  were  not  benefited. 

Soon  after  Professor  Hildebrandt  made  his  first  report  of  cases.  Dr. 
Bengelsdorf  read  a  paper  upon  the  subject  at  a  meeting  of  the  Griefs- 
wald  Medical  Society.  He  alluded  to  four  cases  in  which  he  had 
used  the  hypodermic  injections  of  ergot.  Two  of  these  were  in  pa- 
tients after  the  menopause ;  neither  of  them  seemed  to  be  influenced 
by  the  treatment.  In  the  other  two  the  patients  were  menstruating 
and  the  subjects  of  severe  metrorrhagia.  This  symptom  in  both  cases 
was  very  much  mitigated,  but  the  tumors  were  not  materially,  if  at 
all  diminished  in  size.  Treatment  was  interrui3ted  in  one  of  them 
after  the  administration  of  sixteen  injections.  Dr.  Bengelsdoi'f  was 
favorably  impressed  by  the  treatment. 


CASES.  629 

Dr.  Chrobak,  of  Vienna,  reports,  in  the  seventh  volume,  second 
number,  of  the  Archives  fur  Gyndcologie,  nine  cases.  In  the  first,  the 
tumor  the  size  of  a  small  apple  was  partially  expelled  from  the  cavity 
of  the  body  into  the  cervical  canal;  the  mouth  of  the  uterus  was 
dilated  by  sponge,  and  the  protruding  segment  removed  with  the 
scissors.  In  case  second,  after  forty -three  injections,  the  tumor, 
which  was  situated  in  the  posterior  wall  of  the  uterus,  was  not  re- 
duced in  size,  but  the  hemorrhage  was  cured.  The  tumor  in  case 
third  consisted  of  several  nodules  in  the  anterior  wall  of  the  uterus ; 
after  twenty-four  injections,  there  was  no  diminution  in  size,  but  the 
hemorrhage  was  cured.  In  case  fourth  the  tumor  was  situated  in 
the  posterior  wall  and  reached  up  to  the  umbilicus ;  after  three  in- 
jections the  treatment  was  discontinued  on  account  of  the  pain  and 
inflammation  caused  by  them.  In  the  fifth  case  the  amount  of  hem- 
orrhage was  reduced,  but  the  treatment  was  discontinued  for  the  same 
reason  as  in  case  fourth.  The  tumor  in  case  sixth  was  large,  the 
uterus  rising  above  the  umbilicus;  after  twelve  injections  without 
results,  the  patient  could  not  be  induced  to  receive  further  treatment. 
The  seventh  patient  was  fifty-seven  years  old,  and  the  tumor  showed 
a  multitudinous  development;  the  second  injection,  which  was  ad- 
ministered eight  days  after  the  first,  caused  severe  symptoms  of 
collapse,  and  the  treatment  was  discontinued.  The  tumor  in  the 
eighth  case  was  in  the  anterior  wall  of  the  uterus  and  reached  above 
the  umbilicus,  and  the  monthly  flow  continued  from  eight  to  ten 
days ;  seven  injections  were  used,  with  diminution  of  the  tumor  and 
improvement  in  the  hemorrhages ;  the  treatment  in  this  case  he  ex- 
pected to  continue  at  some  future  time.  In  the  ninth  case  the  uterus 
was  anteverted,  and  the  cavity  measured  four  and  three-fourths  inches 
in  length  ;  after  twelve  injections  the  hemorrhages  ceased  and  the 
tumor  diminished  in  size ;  the  uterine  cavity  measuring  only  three 
and  one-third  inches  in  length. 

Dr.  Lombe  Atthill  records  three  cases  in  the  Irish  Hospital  Gazette 
for  September  1st,  1874.  The  first  case  was  benefited  in  the  diminu- 
tion of  the  flow  and  the  improvement  of  health.  The  second  case 
was  under  treatment  but  a  very  short  time  ;  only  five  injections  were 
administered,  when  the  patient  refused  to  permit  another  because  of 
the  severe  inflammation  following  them.  The  third  case  was  bene- 
fited, but  abandoned  from  the  same  cause. 

Dr.  J.  P.  White,  of  Buffalo,  N.  Y.,  writes  me  that  he  believes  it  is 
in  this  direction — the  use  of  ergot — we  must  look  for  relief  in  the 
intramural  and  non-pediculated  varieties  of  uterine  fibroids.  He  says 
that  in  the  last  year  and  a  half  he  has  resorted  to  ergot  in  these  vari- 
eties with  marked  benefit.  In  a  few  instances  they  have  been  com- 
pletely absorbed,  and  in  a  larger  number  the  growth  of  them  was 
arrested,  the  tumors  were  diminished  in  size,  and  the  hemorrhages  were 


630  FIBROUS    TUMORS    OF   THE    UTERUS. 

suspended.  He  says  that  the  number  of  his  cases  is  fourteen,  and 
that  not  more  than  one-third  can  be  called  cured,  while  in  almost  the 
same  proportion,  the  growth  has  been  stayed  or  diminished,  and  the 
bleeding  arrested. 

Dr.  E.  W.  Jenks,  of  Detroit,  Michigan,  now  of  Chicago,  in  a  recent 
letter,  says,  he  has  used  ergot  during  the  past  two  years  in  the  treat- 
ment of  fibroid  tumors  of  the  uterus  with  the  most  gratifying  results. 
Seventy-five  per  cent,  of  all  cases  thus  treated  were  benefited,  as 
manifested  by  arrest  of  growth  and  control  of  hemorrhage.  About 
ten  per  cent,  of  the  patients  he  considered  cured. 

Dr.  H.  C.  Howard,  of  Champaign,  111.,  sends  me  an  account  of  two 
cases  treated  by  him.  The  first  case  was  in  an  unmarried  woman. 
The  tumor  was  one  originating  from  a  single  nucleus,  intramural, 
and  as  large  as  a  pint  measure.  He  administered  hypodermic  injec- 
tions of  ergotin  for  some  weeks,  and  afterward  continued  treatment 
for  eight  months  by  administering  internally  the  fluid  extract  of  ergot 
and  belladonna.  This  case,  he  says,  was  entirely  cured  by  his  treat- 
ment. His  second  case  was  in  the  person  of  a  married  woman,  forty 
years  of  age,  and  the  mother  of  two  children.  When  first  seen  by 
him  she  had  been  the  subject  of  severe  floodings  for  three  years.  He 
found,  upon  examination,  a  submucous  fibroid  as  large  as  a  quart 
cup.  He  used  large  quantities  of  ergot  by  vaginal  injections  and  by 
the  mouth  for  four  months,  at  which  time  the  tumor  had  entirely 
disappeared. 

Dr.  A.  Reeves  Jackson  reported  to  the  Chicago  Society  of  Physi- 
cians and  Surgeons,  April  13th,  1874,  five  cases  of  fibrous  tumors  of 
the  uterus  treated  by  hypodermic  injections  of  the  solution  of  the 
solid  extract  of  ergot.  The  tumors  in  four  of  these  cases  were  intra- 
mural; in  the  fifth  the  tumor  was  subperitoneal.  The  tumor  in  one 
was  entirely  cured ;  in  two  others  the  tumors  were  greatly  diminished 
in  size.  In  another  the  tumor  seemed  unaffected,  but  the  profuse 
hemorrhages  from  which  the  patient  suffered  were  diminished  in  fre- 
quency and  profuseness.  The  fifth,  a  subperitoneal  tumor,  was  not 
benefited. 

Dr.  Jackson  reports  to  me  three  other  cases.  One  was  in  a  colored 
woman ;  the  uterus  reached  to  the  umbilicus ;  it  was  entirely  cured 
in  three  months.  In  the  second  the  tumor  reached  above  the  umbili- 
cus ;  this  was  temporarily  reduced  in  size  by  the  ergot,  but  after 
treatment  was  abandoned,  it  regained  its  former  dimensions.  The 
treatment  was  discontinued  by  the  patient  because  of  the  distressing 
pain  and  contractions  which  occurred  after  eight  weeks'  use.  The 
profuse  uterine  hemorrhage  was  checked,  and  health  improved. 

At  the  same  meeting  of  the  Society  of  Physicians  and  Surgeons  at 
which  Dr.  Jackson's  first  five  cases  were  reported.  Dr.  Etheridge 
reported  one  case  entirely  cured.     His  diagnosis  was  confirmed  by 


CASES.  631 

Drs.  Gunn  and  Miller,  Dr.  Etheridge's  associate  professors  in  Rush 
Medical  College.  Dr.  Fisher  also  reported  an  intramural  fibrous 
tumor  cured  in  six  weeks.  I  saw  this  case,  and  have  no  doubt  of 
the  correctness  of  Dr.  Fisher's  diagnosis. 

On  the  same  occasion  Dr.  Merriman,  one  of  my  colleagues,  re- 
ported three  cases  ;  one,  intramural,  in  the  anterior  wall,  cured  ;  one, 
subperitoneal,  pediculated ;  the  health  of  this  patient  was  much  im- 
proved, and  the  growth  of  the  tumor  checked  ;  the  patient  was  still 
under  treatment.  The  tumor  in  the  third  was  intramural.  At  the 
time  of  reporting,  the  size  was  gradually  diminishing. 

Dr.  John  Morris,  of  Baltimore,  Md.,  communicates  to  me  a  case 
that  seemed  to  be  decidedly  benefited  by  the  ergot  treatment ;  but, 
on  account  of  the  violent  uterine  contractions  produced  by  the  remedy, 
the  patient  would  not  consent  to  continue  the  treatment. 

Dr.  Charles  E.  Buckingham,  of  Boston,  Mass.,  has  tried  hypodermic 
injections  of  ergot  in  the  treatment  of  fibrous  tumors  of  the  uterus  in 
but  one  case.     The  result  was  entirely  negative. 

Dr.  George  Cowan,  of  Danville,  Ky.,  reports  a  case  in  the  person  of 
a  colored  woman,  unmarried,  and  about  forty  years  of  age.  The  hypo- 
dermic injections  of  ergotin  were  used  for  two  weeks.  At  the  end  of 
this  time  the  greatest  circumference  of  the  abdomen  was  reduced  from 
thirty-six  inches,  which  it  measured  before  the  treatment  was  insti- 
tuted, to  twenty-eight  and  one-half  inches.  The  patient,  returning 
home,  used  the  injections  herself.  Such  frequent  and  painful  abscesses 
ensued,  however,  that  she  discontinued  them.  During  the  use  of  the 
injections  an  obstinate  constipation  was  removed,  and  her  general 
health  much  improved.  The  abandonment  of  the  treatment  was  fol- 
lowed by  a  return  of  the  constipation,  loss  of  flesh,  great  debility,  and 
the  abdomen  increased  in  size  until  it  measured  thirty-two  inches. 
A  return  to  the  treatment  was  followed  by  the  same  marked  improve- 
ment in.  the  general  health,  and  a  reduction  of  the  size  of  the  abdomen 
to  twenty-seven  and  one-fourth  inches. 

Dr.  H.  W.  Dean,  of  Rochester,  N.  Y.,  sends  me  an  account  of  two 
cases  treated  by  him.  The  first  case  was  that  of  a  patient  forty -seven 
years  of  age,  the  mother  of  three  children,  the  age  of  the  youngest 
nineteen.  She  suffered  from  pressure  upon  the  bladder  and  rectum, 
and  was  the  subject  of  severe  menorrhagia.  The  tumor  extended  two 
inches  above  the  umbilicus,  and  occupied  the  lower  half  of  the  right 
lumbar,  the  whole  of  the  right  inguinal,  and  fully  half  of  the  corres- 
ponding left  abdominal  regions.  The  os  uteri  was  a  little  to  the  left 
of  its  natural  position,  and  sufficiently  open  to  admit  the  finger  half 
an  inch.  An  elastic  catheter  was  introduced  into  the  uterine  cavity 
between  seven  and  a  half  and  seven  and  three-fourths  inches.  The 
diagnosis  was  interstitial  fibrous  tumor  of  the  uterus.  Intrauterine 
injections,  through  the  elastic  catheter,  of  half  a  drachm  of  Squibb's 


632  FIBROUS    TUMOES    OF    THE    UTERUS. 

fluid  extract  of  ergot  were  made  four  times  during  each  menstrual  in- 
terval, from  April  until  October,  1874.  Injections  into  the  substance 
of  the  cervix  were  made  with  the  same  frequency  from  October  to  the 
middle  of  December.  The  results  were,  reduction  in  the  size  of  the 
tumor  until  the  upper  margin  sank  two  inches  below  the  umbilicus, 
and  the  uterine  cavity  measured  only  four  and  a  half  inches. 

The  second  case  was  that  of  a  woman,  forty-eight  years  of  age,  the 
mother  of  three  children,  the  youngest  of  whom  was  sixteen.  She 
flowed  irregularly,  the  intervals  varying  from  one  to  three  weeks.  The 
flow  was  profuse  and  attended  with  great  pain.  In  the  intervals  there 
was  a  copious  flow  of  serous  leucorrhoea.  She  also  suffered  from 
pressure  upon  the  bladder  and  frequent  micturition.  The  tumor  oc- 
cupied the  right  side  of  the  abdomen,  extending  nearly  to  the  umbili- 
cus, and  to  midway  between  the  linea  alba  and  the  left  ilium.  The 
vagina  could  not  be  satisfactorily  explored  until  the  hand  was  intro- 
duced. When  this  was  effected  the  finger  could  be  easily  passed  into 
the  uterus.  Between  the  finger  thus  introduced  and  the  hand  on  the 
hypogastric  region,  the  presence  of  an  interstitial  fibrous  tumor  was 
diagnosticated.  A  flexible  catheter  was  passed  into  the  uterine  cavity 
to  the  extent  of  eight  inches.  Injection  into  the  substance  of  the 
cervix  was  followed  in  fifteen  minutes  by  continuous  uterine  contrac- 
tions, which  lasted  twenty -four  hours.  This  injection  was  repeated 
four  times  a  month.  When  the  amount  was  increased  from  fifteen  to 
twenty  minims,  great  gastric  and  cerebral  disturbance,  together  with 
intense  cutaneous  engorgement  and  uterine  pain,  ensued.  The  injec- 
tions were  continued  from  November,  1873,  to  the  middle  of  the  year 
1874.  At  this  time  the  upper  margin  of  the  tumor  was  but  one  inch 
above  the  symphysis  pubis,  and  the  cavity  of  the  uterus  measured 
four  and  a  half  inches.  Menstruation  was  quite  normal  as  to  time 
and  quantity,  and  attended  with  little  pain.  The  pelvic  organs  were 
not  subject  to  disagreeable  pressure. 

Dr.  W.  C.  Wey,  of  Elmira,  N.  Y.,  in  a  lengthy  and  interesting  letter 
gives  me  the  results  of  his  treatment  in  one  case.  The  patient  was 
forty-seven  years  old.  The  bulk  of  the  tumor  Avas  equal  to  both  closed 
hands.  It  was  reduced  in  six  weeks  about  one-third,  and  in  six  months 
to  one-half  of  its  original  size.  The  patient,  before  the  treatment,  was 
very  much  reduced  ;  her  extremities  had  become  oedematous,  and  ex- 
ercise was  impossible  from  the  effects  of  hemorrhage,  which  had 
become  almost  constant.  These  symptoms  were  relieved  with  great 
promptitude  and  in  four  months  tlie  menses  had  become  normal  in 
every  respect.  His  treatment  was  continued  twenty -seven  months, 
but  most  of  the  good  results,  if  not  all,  were  obtained  in  the  first  six 
months. 

Dr.  Edward  M.  Hodder,  of  Toronto,  writes  me  that  the  number  of 
cases  in  his  notebook,  since  May,  1873,  is  twenty-five ;  but  all  of  these 


CASES.  633 

reside  at  a  distance,  and  therefore  he  saw  or  heard  of  them  only  oc- 
casionally. Nearly  the  whole  of  them  were  treated  with  ergot,  but 
not  exclusively,  as  he  combined  with  it  the  bromide  and  iodide  of 
potassium.  In  the  majority  of  the  cases,  treatment  appeared  to  arrest 
further  growth,  and  after  a  time  caused  the  tumors  to  diminish  in 
size.  In  a  few  cases  the  tumors  disappeared  entirely.  He  gives  four 
cases  in  minutiae :  in  one  case  the  treatment  was  commenced  May, 
1873;  tlie  tumor  nearly  disappeared,  and  the  patient  is  now  six  or 
seven  months  advanced  in  pregnancy.  In  the  second  case,  the  treat- 
ment was  begun  in  June,  1873 ;  the  tumor  was  greatly  diminished 
in  size,  the  patient  became  pregnant,  and  was  delivered  late  last 
autumn.  In  the  third  case  the  treatment  was  commenced  in  Sep- 
tember, 1873 ;  the  tumor  disappeared,  and  the  patient  is  now  preg- 
nant. In  the  fourth  case  treatment  was  commenced  in  September, 
1873,  and  the  tumor  is  now  nearly  gone,  and  the  patient  feels  quite 
well. 

Through  the  kindness  of  Dr.  Hodder  I  have  received  the  report  of 
another  case  by  Dr.  Jukes,  of  St.  Catherines.  The  tumor  was  discov- 
ered b}^  Dr.  Jukes  at  the  time  of  delivery  after  a  normal  pregnancy. 
The  history  of  the  case  shows  that  its  existence  had  been  recognized 
by  Dr.  Hodder  before  the  patient  was  married.  Dr.  Jukes  gave  the 
fluid  extract  of  ergot  continuously  to  this  patient  for  three  months, 
first  in  doses  of  one-half  drachm,  and  afterwards  increased  the  dose 
to  one  drachm,  combined  with  the  various  preparations  of  iodine. 
From  the  beginning,  the  tumor  slowly  decreased  in  size,  and  at  the 
end  of  three  months  had  entirely  disappeared.  Some  weeks  after  de- 
livery, lie  passed  the  sound  into  the  uterine  cavity  six  inches,  and  the 
organ  reached  very  nearly  to  the  umbilicus.  After  the  three  months' 
treatment  the  measurement  by  the  sound  showed  the  organ  to  be  very 
slightly  above  its  normal  size. 

Dr.  Strange,  of  Aurora,  Canada,  says  that  he  had  on  several  occa- 
sions given  ergot  internally  to  arrest  the  hemorrhage  attendant  upon 
fibrous  growths  in  the  uterus,  and  had  observed  that  it  tended  to  re- 
tard their  further  growth. 

Dr.  L.  F.  Warner,  of  Boston,  has  used  ergot  in  two  cases  of  fibrous 
tumors  of  the  uterus,  but  could  perceive  no  beneficial  effects. 

Dr.  J.  H.  Thompson,  Surgeon  in  Chief  of  the  Columbia  Hospital 
for  Women  and  Children,  reports  three  cases  treated  by  ergot,  in  all  of 
which  the  tumors  were  reduced  in  size,  the  metrorrhagia  cured,  and 
the  general  health,  which  in  all  was  much  impaired,  was  entirely  re- 
stored. In  one  of  these  cases  Dr.  Thompson  injected  the  ergot  into 
the  substance  of  the  tumor  by  passing  this  instrument  through  the 
cervical  cavity,  and  thence  penetrating  the  growth.  No  unpleasant 
effects  followed  this  method  of  using  the  remedy. 

Dr.  Russel,  of  Oshkosh,  Wisconsin,  reports  one  case  in  which  the 


634  FIBROUS    TUMORS    OF   THE    UTERUS. 

tumor,  of  large  size,  was  very  much  reduced,  and  all  the  disagreeable 
symptoms  were  removed. 

During  the  year  since  the  last  meeting  of  the  Association  I  have 
treated  seven  cases. 

One  was  not  affected  by  the  ergot,  and  the  patient  died  six  weeks 
after  the  commencement  of  the  treatment.  She  was  anfemic  to  a  de- 
gree which  I  have  seldom  before  seen.  The  remedy  was  administered 
hypodermically  every  day,  thirty  drops  of  Squibb's  solution  of  the 
solid  extract  being  injected  each  time. 

The  second  patient  was  the  subject  of  a  uninuclear  tumor,  situated 
in  the  anterior  wall  of  the  uterus,  about  the  size  of  the  fetal  head.  She 
had  profuse  hemorrhages  at  her  menstrual  periods,  and  copious  leu- 
corrhoeal  discharges  between  them,  and  had  become  very  angemic. 
The  discharge  ceased  and  the  tumor  disappeared  in  five  months  from 
the  time  she  first  came  under  my  care.  The  remedy  was  at  first  used 
hypodermically ;  but,  on  account  of  the  pain  and  inflammation  at  the 
punctures,  I  was  obliged  to  cease  this  mode  of  administering  it,  and 
gave  it  internally.  Teaspoonful  doses  of  Squibb's  fluid  extract  were 
given  twice  a  day  for  the  last  three  months  of  the  time  the  patient  was 
under  treatment. 

In  three  other  cases,  in  which  the  medicine  was  given  internally, 
the  tumors  were  very  much  reduced  in  size,  but  did  not  disappear. 
The  hemorrhages  and  leucorrhoea  were  cured,  and  the  j)atients  restored 
to  health. 

In  another,  the  hemorrhages  and  leucorrhoea  were  rendered  much 
less  profuse,  but  the  tumor  was  not  reduced  in  size. 

In  a  colored  senile  patient,  over  sixty  years  of  age,  with  a  large 
multiple  tumor,  no  effect  was  produced  by  the  ergot. 

In  four  of  my  cases  I  was  obliged  to  suspend  the  treatment  several 
times  for  a  few  days,  to  give  the  patients  a  respite  from  the  almost 
constant  pain. 

Five  of  these  complained  of  great  heat  and  tenderness  of  the  uterus 
after  they  had  been  under  treatment  about  four  weeks. 

In  all,  the  pulse  was  accelerated  and  remained  small  and  weak. 

As  one  of  my  cases  presented  some  features  of  more  than  ordinar}'' 
interest,  I  will  give  it  more  in  detail :  The  patient  had  been  married 
twelve  years,  was  thirtj^-seven  years  old,  and  sterile.  She  had  been 
aware  of  the  existence  of  the  tumor  for  three  years,  but  could  not 
give  a  very  clear  history  of  its  progressive  enlargement.  The  uterus 
extended  three  inches  above  the  pubes,  and  was  a  little  to  the  right  of 
the  median  line,  very  hard,  and  irregular  in  shape ;  but  I  could  not 
discover  that  there  were  subperitoneal  nodules.  Per  vaginam,  the 
tumor  could  be  felt  to  occupy  the  right  side  and  anterior  wall  of  the 
uterus,  and  fill  up  two-thirds  of  the  pelvic  cavity.  The  cavity  of  the 
uterus  measured  four  and  a  quarter  inches.     A  polypus,  jDyriform  in 


CASES.  635 

shape,  quite  firm  in  consistence,  about  the  size  of  a  pigeon's  egg,  de- 
pended from  the  mouth  of  the  uterus,  and  appeared  to  be  attached 
to  the  upper  part  of  the  posterior  wall  of  the  cervix.  The  diagnosis 
was  intramural  fibrous  tumor  of  the  uterus,  with  two  nuclei  of  devel- 
opment, and  a  fibrous  polypus.  The  patient  was  somewhat  anpemio 
from  the  long  continuance  of  profuse  leucorrhoea  and  metrorrhagia. 
Without  removing  the  polypus,  I  commenced  treatment  by  giving 
the  patient  three  grains  of  the  solid  extract  of  ergot  three  times  a  day. 
The  next  menstrual  flow  was  not  so  profuse,  and  the  leucorrhoea  di- 
minished almost  from  the  beginning.  At  the  end  of  four  months  the 
menstruation  was  normal,  the  leucorrhoea  had  ceased,  the  tumor  was 
reduced  to  half  its  former  dimensions,  and  the  patient's  health  re- 
stored. A  continuation  of  the  treatment  two  months  longer  causing 
no  further  reduction  of  the  tumor,  it  was  suspended.  During  the 
treatment,  I  watched  with  much  interest  the  effects  produced  upon  the 
polypus,  examining  it  once  in  every  ten  or  twelve  days.  It  showed 
decided  decrease  in  size  at  the  end  of  the  first  ten  days,  and  progres-- 
sively  decreased  until,  at  the  expiration  of  four  months,  it  was  not 
more  than  one-third  the  size  it  presented  when  first  examined.  It  was 
twisted  off  at  this  time  with  great  ease,  and  its  removal  was  followed 
by  almost  no  loss  of  blood. 

The  most  remarkable  case  of  which  I  have  any  knowledge  was  re- 
ported to  me  by  Dr.  G.  C.  Goodrich,  of  Minneapolis,  in  which  absorp- 
tion of  a  large  tumor  took  place  under  the  administration  of  ergot  and 
belladonna.     I  subjoin  his  description : 

"The  treatment  was  commenced  in  1870,  and  continued  two  years.  The  uterus 
filled  the  whole  apace  between  the  ilia,  and  measured  in  the  transverse  diameter 
twelve  inches,  and  in  the  vertical  nineteen  inches,  extended  up  under  the  ensiform 
cartilage  and  close  up  to  the  margin  of  the  cartilages  of  the  ribs.  The  treatment  was 
followed  by  cramps  in  the  uterus,  which  produced  a  wild  enthusiasm  in  the  mind  of 
the  patient,  and  inspired  her  with  strong  hopes  of  recovery.  Without  consulting  me, 
she  doubled  the  dose  of  medicine,  which  was  administered  internally,  and  as  a  conse- 
quence she  was  attacked  with  very  strong  uterine  contractions  and  symptoms  of  me- 
tritis. This  caused  me  to  abandon  treatment  for  about  one  month,  and  had  it  not  been 
for  the  urgent  determination  of  the  patient,  I  would  not  have  resumed  it.  She  in- 
sisted that  as  this  was  the  first  medicine  which  had  ever  affected  the  enlarged  organ,, 
she  believed  it  would  cure  her,  and  promised  to  obey  my  directions  if  I  would  pro- 
ceed. She  so  promptly  and  rapidly  improved  that  I  doubted  if  it  were  not  a  coinci- 
dence with,  rather  than  a  consequence  of,  the  treatment.  Prompted  by  this  doubt,  I 
abandoned  the  use  of  the  ergot  and  belladonna  and  continued  alterative  treatment. 
The  patient  soon  assured  me  that  she  no  longer  felt  the  griping  pains  caiised  by  the 
remedy,  and  that  the  tumor  was  softer  and  larger  than  when  she  took  the  ergot  pre- 
scription. The  ergot  and  belladonna  were  again  resumed,  and  in  four  months  she 
was  able  to  make  a  trip  to  Boston  alone.  While  absent,  she  continued  to  take  the 
medicine.  From  this  time  she  continued  rapidly  convalescing,  and  is  now  in  the  en- 
joyment of  fine  health."* 

*  The  author's  address  before  the  American  Medical  Association  at  its  meeting  in 
1875. 


636  FIBROUS    TUMORS    OF   THE    UTERUS. 

I  subjoin  cases  in  which  the  tumors  were  expelled  piecemeal  under 
the  administration  of  ergot,  which  came  under  my  own  observation : 

The  first  case  in  which  this  process  was  attained  occurred  in  the 
practice  of  Dr.  H.  P.  Merriman.  So  far  as  I  am  aware  it  is  the  first 
case  on  record.  With  several  other  medical  gentlemen  I  had  the 
opportunity  of  seeing  the  patient  several  times,  fully  verifying  the 
diagnosis,  and  witnessing  the  results  of  the  treatment. 

It  was  recorded  in  my  address  before  the  American  Medical  Asso- 
ciation already  referred  to.     Dr.  Merriman  says : 

"  Mrs.  K.,  aged  thirty,  the  mother  of  three  children,  came  to  me  in  September,  1874, 
in  regard  to  a  tumor  in  the  abdomen.  Examination  revealed  a  large  tumor  about  the 
size  of  a  four  and  a  half  months'  pregnancy  ;  it  was  found  to  be  interstitial,  and  situ- 
ated on  the  right  side  and  a  little  anterior;  the  sound  passed  six  and  three-fourths 
inches.  She  was  at  once  given  twenty  drops  of  fluid  extract  of  ergot  (Squibb's)  three 
times  a  day.  She  came  a  month  later  saying  she  was  much  better  in  health,  but  the 
tumor  remained  the  same.  I  told  her  to  continue  the  medicine,  but  to  increase  the 
dose  to  twenty-five  drops  and  after  a  time  to  thirty.  I  have  seen  her  three  or  four 
times  during  the  past  winter,  and  twice  had  to  suspend  treatment  and  give  opium  on 
account  of  severe  pain  and  tenderness  in  the  uterine  region.  Finally,  March  23d, 
1875,  I  stopped  all  use  of  ergot,  as  the  patient  was  very  weak,  the  pulse  110,  the  appe" 
tite  poor,  and  a  very  offensive  and  abundant  discharge  was  coniing  from  the  uterus. 
The  OS  uteri  was  very  patulous.  On  April  5th,  I  was  summoned  in  great  haste.  Some- 
thing had  just  come  away  from  the  patient.  I  found  it  to  be  an  offensive  fleshy  mass, 
evidently  a  disintegrated  fibrous  tumor.  Examination  showed  no  tumor  in  the  abdo- 
men, but  per  vaginam  the  os  patulous,  soft,  and  very  sensitive,  and  the  uterus  still 
large.     A  week  latter  the  uterus  had  regained  its  normal  condition." 

As  an  evidence  of  the  complete  restoration  of  the  health  of  the  pa- 
tient, Dr.  Merriman  informs  me  that  she  has  since  had  a  fine  healthy 
child. 

The  next  case,  which  has  never  been  published,  occurred  in  my 
own  practice,  and  I  will  give  a  brief  account  of  it:  Mrs.  W.,  forty 
years  of  age,  had  been  married  eighteen  years,  and  had  not  borne 
children  or  been  pregnant.  She  had  enjoyed  good  health  and  noticed 
nothing  unusual  in  her  menses  until  about  three  years  before  she  con- 
sulted me  on  July  17th,  1875.  Three  years  ago  she  began  to  have 
an  increased  menstrual  flow,  the  intervals  were  shorter,  and  she  be- 
came the  subject  of  an  acrid  leucorrhoeal  discharge.  For  the  last 
seven  or  eight  months  the  flow  has  been  almost  constant,  but  moder- 
ate. The  catamenial  periods  had  been  during  the  time  well  marked 
by  a  profuse  discharge  every  four  weeks.  She  was  quite  feeble  from 
the  great  loss  of  blood  she  had  sustained,  very  nervous  and  dispirited. 
For  more  than  a  year  she  had  been  conscious  of  the  presence  of  a 
tumor  in  the  hypogastric  region.  She  had  at  no  time  observed  that 
the  discharge  was  fetid,  or  indeed  had  any  smell.  By  palpation,  a 
tumor  could  be  found  extending  to  within  about  two  inches  of  the 
umbilicus,  and  filling  up  the  same  space  in  the  lower  part  of  the  ab- 


CASES.  637 

domen  which  the  uterus  occupies  at  five  months'  pregnancy.  It  was 
globular,  very  hard,  somewhat  nodulated  in  shape,  and  movable. 
The  cervix,  when  examined  per  vaginam,  was  ascertained  to  be  long 
and  pointed,  and  the  mouth  small,  and  not  at  all  patulous.  The 
probe  entered  the  uterine  cavity,  passing  upward  and  backward  fully 
four  inches,  and  moved  with  the  impressions  made  upon  the  tumor 
above  the  S3'mphysis. 

From  the  history  and  examination  it  was  not  difficult  to  diagnose 
a  fibrous  tumor  in  the  anterior  wall  of  the  uterus. 

I  prescribed  thirty  drops  of  the  fluid  extract  of  ergot  three  times  a 
day,  to  be  taken  in  a  wineglassful  of  water,  and  large  injections  of 
cold  water  twice  a  day. 

On  July  19th  the  patient  called  to  see  me  again.  She  informed 
me  that  the  medicine  had  caused  great  pain  in  the  tumor,  resembling 
cramps,  with  a. strong  desire  to  bear  down,  as  though  something  was 
coming  out  of  her.  An  examination  revealed  no  change  in  the  size 
of  the  tumor,  but  increased  hardness  and  irregularity  of  its  surface. 
She  was  directed  to  continue  the  medicine.  On  the  25th  the  patient 
complained  that  the  pains  were  almost  unendurable  on  account  of 
their  severity  and  continuousness.  She  said  they  prevented  her  from 
sleeping,  or  resting  in  any  position.  For  the  two  days  previous  to 
her  call  on  the  25th  she  had  noticed  in  the  discharges — which  were 
less  bloody — stringy  and  lumpy  substances.  This  was  different  from 
anything  she  had  seen  before.  Still  there  was  no  fetor.  The  tumor 
seemed  to  be  somewhat  less  in  size  than  upon  the  first  examination. 
There  were  some  changes  in  the  cervix ;  it  was  soft,  and  the  mouth 
was  patulous ;  the  finger  entered  it  a  short  distance,  but  would  not 
pass  the  inner  os  uteri.  The  cervix  was  still  as  long  as  before  the 
commencement  of  the  pains,  and  I  thought  the  lower  portion  of  the 
tumor  seemed  more  elastic  than  at  first. 

On  the  27th  the  pain  was  so  severe  and  persistent  that  I  thought  it 
advisable  to  diminish  the  doses  of  ergot,  and  directed  her  to  take  only 
fifteen  drops  three  times  a  day.  The  discharge  was  increasing  in 
quantity,  and  she  gave  me  several  pieces,  one  of  which  was  as  large  as 
a  cherry.  It  was  so  firm  that  it  was  difficult  to  break  it  up  with  the 
fingers,  and  of  grayish  color.  There  was  no  odor  that  I  could  dis- 
cover in  the  piece  examined. 

Dr.  W.  H.  Warn  was  kind  enough  to  examine  this  specimen  with 
the  microscope.  He  found  it  composed  mostly  of  hypertrophied  con- 
nective-tissue fibres,  with  bloodvessels  running  parallel  to  them.  The 
tumor  had  decidedlj^  decreased  in  size. 

On  July  31st  the  pains,  with  less  severity,  were  still  continuous  for 
the  greater  part  of  the  day  and  night.  There  was  a  constant  discharge 
of  these  small  fibrous  lumps.  Juaging  from  a  close  examination,  the 
tumor  was  not  half  so  large  as  when  first  seen. 


638  FIBROUS    TUMORS    OF   THE    UTERUS. 

The  discharge  continued  without  diminution  until  the  fifteenth  of 
August,  when  it  became  less,  and  the  pain  also  decreased.  At  this 
time  the  upper  part  of  the  tumor  could  barely  be  felt  above  the  sym- 
physis. The  cervix  was  still  long,  but  the  mouth  was  less  patulous, 
and  the  probe  would  not  pass  more  than  two  and  a  half  inches. 

Since  the  commencement  of  treatment  the  bloody  discharge  has 
not  indicated  a  menstrual  flow.  In  fact,  the  bloody  discharge  became 
progressively  less,  until  it  had  entirely  ceased  about  the  middle  of 
August. 

The  patient's  health  greatly  improved,  and  she  was  permitted  to 
return  to  her  home  in  the  country.  She  wrote  me  on  the  1st  of 
September  that  she  still  suffered  pain,  and  the  discharge  still  con- 
tinued, but  that  it  now  had  the  appearance  of  pus,  and  was  somewhat 
fetid  for  the  first  time.  In  October  she  wrote  me  again  to  say  that 
there  was  no  sign  of  the  tumor;  she  had  no  pain  and  never  enjoyed 
better  health.  She  had  menstruated  twice  since  she  had  returned 
home,  but  the  discharge  at  both  periods  was  inoderate,  and  she  had 
no  pain.     She  continued  the  ergot  up  to  the  middle  of  September. 

Mrs.  Arthur  King,  of  Sterling,  Illinois,  called  on  me  December 
13th,  1875.  She  was  thirty-five  years  old,  married,  and  had  never 
been  pregnant. 

On  the  1st  of  the  preceding  June  she  noticed  a  circumscribed  hard 
lump  two  inches  below  and  to  the  left  of  the  umbilicus.  She  was  the 
subject  of  serious  uterine  and  sympathetic  symptoms,  for  which  she 
had  at  different  times  had  treatment.  She  had  profuse  menorrhagia, 
leucorrhoea,  and  great  sense  of  weight  in  the  pelvis. 

Upon  examination  I  found  a  hard,  round,  movable  tumor,  extend- 
ing up  to  within  two  inches  of  the  umbilicus,  filling  up  the  whole  of 
the  right  iliac,  the  hypogastric,  lower  half  of  the  umbilical,  and  more 
than  half  of  the  left  iliac  regions. 

The  contour  of  the  tumor  was  somewhat  uneven,  though  not  dis- 
tinctly nodular.  The  cervix  was  long,  pointed,  and  thrown  backward 
and  to  the  left.  The  sound  entered  the  small  uterine  mouth  and 
passed  upward,  backward,  and  to  the  left  five  and  a  half  inches. 

The  diagnosis  was  a  fibrous  tumor  of  the  right  anterior  wall  of  the 
uterus.  I  prescribed  thirty  drops  of  Squibb's  fluid  extract  of  ergot 
to  be  taken  three  times  a  day.  She  went  home,  but  did  not  commence 
taking  the  medicine  until  the  20th  of  December.  On  the  26th  of 
December  Dr.  J.  B.  Crandall  was  called  to  see  her,  and  describes  her 
condition  as  follows: 

"The  patient  was  in  a  state  of  great  nervous  prostration,  and  worn  out  by  severe 
pain  and  loss  of  sleep.  The  pains  commenced  soon  after  taking  tlie  second  dose  of 
ergot,  and  were  excruciatingly  severe  for  about  three  hours,  after  which  they  con- 
tinued less  severely  for  two  days  and  nights.     She  had  more  or  less  hemorrhage  from 


CASES.  639 

the  uterus  after  taking  the  ergot.  Her  pnlse  was  feeble,  110  to  120  to  the  minute. 
The  skin  was  hot  and  dry,  and  she  complained  of  great  pain  and  tenderness  over  the 
uterus  and  lower  bowels.  The  feet  were  drawn  up,  and  the  face  wore  a  pinched  and 
peculiar  expression." 

Under  these  circumstances  the  doctor  administered  anodynes,  tonics, 
and  nourishment,  to  the  great  relief  of  the  patient. 

On  January  11th,  1876,  the  patient  began  to  pass  from  the  vagina 
small  masses  of  fibrous  substance,  from  the  size  of  a  chestnut  to  that 
of  an  English  walnut.  The  substances  thus  discharged  were  firm 
and  gray  in  color,  and  were  exceedingly  fetid.  This  discharge  con- 
tinued up  to  the  21st  of  January,  when  the  uterus  was  very  much 
diminished  in  size,  the  tenderness  had  subsided,  and  the  patient  ap- 
peared comparatively  comfortable.  Up  to  that  time  she  had  taken 
but  three  doses  of  ergot,  on  the  20th  of  the  preceding  month,  and  the 
doctor  ordered  it  to  be  resumed  again.  This  time  the  ergot  produced 
no  pain,  and  after  three  or  four  days  was  discontinued.  From  the  21st 
of  January  there  were  no  more  pieces  discharged,  but  up  to  February 
1st  a  yellowish,  thin,  offensive  fluid  passed  from  the  vagina  in  con- 
siderable quantities.  On  the  first  day  of  February  the  ergot  was  again 
ordered  and  continued  two  weeks,  when,  as  no  results  ensued,  it  was 
finally  dropped. 

Dr.  Crandall  states  that  on  the  14th  of  February  the  uterus  was  re- 
duced to  its  normal  size,  and  on  the  26th  the  patient  was  up  and  about 
'  her  work,  completely  cured.  He  remarked,  in  this  connection,  that 
the  first  three  doses  of  ergot  taken  by  the  patient  was  the  cause  of  her 
recovery. 

This  case  is  published  in  the  August  (1875)  number  of  the  Chicago 
Medical  Journal  and  Examiner^  as  reported  by  Dr.  Crandall. 

Mrs.  L.  D.  M.,  aged  forty-seven  years,  had  a  fibroid  tumor  in  the 
anterior  wall  of  the  uterus,  which,  with  the  enlarged  uterus,  arose  to 
within  two  inches  of  the  umbilicus. 

She  commenced  taking  thirty  drops  of  the  fluid  extract  of  ergot  on 
the  22d  of  Septemper,  1876,  and  was  to  increase  gradually  the  dose 
with  the  object  in  view  of  causing  the  disruption  and  expulsion  of  the 
tumor.  The  ergot  at  first  produced  no  perceptible  effect  until  she  had 
taken  it  ten  days,  when  she  began  to  experience  the  pain  of  contrac- 
tion. The  pain  became  so  severe  and  continuous  that  it  was  necessary 
to  omit  it  for  two  or  three  days  at  a  time.  The  patient  was  intelligent 
and  understood  the  object  and  mode  of  action  of  the  ergot,  and  when 
the  pain  entirely  subsided,  she  courageously  resumed  it  in  the  smaller 
doses,  and  increased  again  until  the  pains  became  intolerable.  On 
the  13th  of  January,  1877,  small  pieces  of  the  tumor  showed  them- 
selves in  the  vaginal  discharges,  and  by  the  26tli  of  the  same  month 
the  whole  of  it  had  been  discharged  piecemeal. 


640  FIBROUS   TUMORS   OF  THE   UTERUS, 

She  wrote  me  on  the  30th  of  January,  saying : 

"  I  think  I  wrote  one  week  ago  to-day.  At  that  time  the  tumor  was  passing.  It 
continued  to  pass  until  the  26th,  when,  I  think,  the  last  was  expelled.  To-day  I  send 
you  by  express  a  portion  of  the  last  that  came.  I  think  the  whole  of  it,  including  the 
portion  I  sent  you,  would  have  weighed  one  and  a  half  pounds.  I  do  not  believe  a 
quart  can  would  hold  it  if  the  whole  had  been  preserved.  It  commenced  to  come  on 
Saturday,  and  from  Saturday  evening  to  Sunday  morning  there  was  a  pint  or  more. 
After  that,  the  stench  was  so  disagreeable  that  we  could  not  cleanse  it,  consequently 
we  threw  it  away.  Wednesday  and  Thursday  it  seemed  to  be  in  one  continuous  mass. 
I  cannot  better  describe  it  than  to  say  that  it  came  like  sausage-meat  from  a  stuffer. 
I  would  cut  off  about  four  inches  a  day,  that  is  on  Wednesday  and  Thursday.  On 
Friday  morning  the  last  of  it  came  away." 

During,  and  for  some  days  after,  the  expulsion  she  suffered  slight 
symptoms  of  septiccemia,  but  recovered  from  them,  and  in  the  course 
of  a  month  afterward  she  visited  me,  when  I  found  the  uterus  meas- 
ured two  inches  and  a  half  in  depth.  She  then  had  some  leucorrhcea, 
but  was  fast  regaining  her  health.  She  is  now  perfectly  well,  and  has 
passed  in  safety  the  menopause."^ 

The  following  case  is  reported  to  me  by  letter  by  William  Fox,  M.D., 
of  Milwaukee,  January  19th,  1880 : 

"  Mrs.  B.,  aged  forty-three ;  last  child  four  years  old ;  did  not  get  up  well.  Men- 
struation returned  earlier  than  usual,  and  gradually  became  more  frequent  and  pro- 
fuse, and  of  longer  duration.  Finally  the  abdomen  began  to  enlarge  so  much  that  her 
friends  believed  her  pregnant.  But  her  health  began  to  fail ;  her  losses  became 
greater,  and  almost  continuous.  She  was  without  treatment,  as  she  believed  her  con- 
dition due  to  her  time  of  life.  An  examination  revealed  a  uterus  as  large  as  at  the 
sixth  month  of  gestation,  and  could  be  easily  felt  and  moved  through  the  abdominal 
walls.  A  sound  entered  five  and  a  half  inches,  and  with  it  in  the  uterus  and  the  hand 
outside,  a  tumor  could  be  felt  in  the  anterior  wall.  The  patient  was  put  upon  30-drop 
doses  of  Squibb's  extract  of  ergot,  four  times  daily,  and  sent  to  consult  Dr.  Byford, 
February  3d,  who  confirmed  the  diagnosis  and  approved  the  treatment,  and  made  a 
prognosis  more  favorable  than  I  believed.  He  said,  with  the  above  treatment  we 
would  starve  the  growth,  and  possibly  expel  it.  The  period  was  detained  a  week, 
when  it  came  on,  February  21st,  five  weeks  from  the  commencement  of  treatment, 
with  a  great  deal  of  pain.  The  ergot  was  continued,  the  pain  increasing,  until,  on  the 
third  day,  I  found  the  patient  with  a  temperature  of  105° ;  pulse,  140,  an  offensive 
discharge,  and  complaining  of  a  feeling  as  of  some  foreign  body  in  the  vagina.  The 
vagina  was  full  of  a  stinking  mass,  not  unlike  a  placenta  in  feel,  but  harder.  The  os 
was  quite  open,  and  the  fingers  could  readily  pass  into  the  uterus  and  describe  the 
growth.  All  the  gangrenous  mass  was  taken  away  as  fast  as  possible  with  the  fingers 
and  forceps,  and  the  uterus  carefully  washed  out  with  carbolized  hot  water  every  four 
hours.     The  ergot  was  discontinued  because  of  the  pain.     Whiskey,  quinine,  and 


*  This  case,  the  abstract  of  which  I  have  here  given,  was  in  the  May  15th,  1877, 
number  of  the  Archives  of  Clinical  Surgery,  N.  Y. 


SUMMARY   OF   CASES   CURED    BY   ABSORPTION.  641 

milk  constituted  the  treatment.  She  rapidly  improved,  and  in  less  than  a  month  was 
out  driving,  walking,  and  feeling  well.  In  six  weeks,  menstruation  returned  ;  came 
on  without  warning  ;  lasted  less  than  three  days  ;  the  first  natural  period  she  remem- 
bers having  had  in  four  years.  She  has  had  three  since,  perfectly  natural  in  every 
way.     She  is  perfectly  well." 

I  have  known  ten  cases  in  which  the  tumors  were  expelled  piece- 
meal by  ergot,  with  but  one  death.  The  death  occurred  in  a  patient 
who  rode  one  hundred  and  fifty  miles  on  a  railroad  train  to  see  me, 
with  pieces  of  the  tumor  hanging  from  the  vagina,  which  she  would 
not  allow  her  physician  to  remove.  When  she  arrived,  I  passed  my 
fingers  up  into  the  contracted  capsule  and  scooped  out  the  remaining 
portion  of  the  tumor.  She  was  so  exhausted,  however,  by  the  journey 
and  the  sepsis,  that  she  died  three  days  afterwards. 

I  cannot  help  believing  that  if  she  had  remained  at  home  and  sub- 
mitted to  the  treatment  of  her  physician,  her  life  need  not  have 
been  sacrificed. 

Summary  of  Cases  cured  by  Absorption. 

The  total  number  of  cases  here  cited  is  one  hundred  and  one. 
Twenty-two  of  them  are  reported  cured.  In  thirty-nine  more  the 
tumors  were  diminished  in  size,  and  the  hemorrhage  and  other  dis- 
agreeable symptoms  removed.  Nineteen  of  the  remainder  were  bene- 
fited by  the  relief  of  the  hemorrhages  and  leucorrhoeal  discharges, 
while  the  size  and  other  conditions  of  the  tumors  were  unchanged. 
Out  of  the  whole  number  only  twenty-one  cases  entirely  resisted  the 
treatment.  This  shows  results  decidedly  favorable  in  eighty  of  the 
one  hundred  and  one  cases. 

We  may  still  further  appreciate  the  favorable  effects  of  the  treat- 
ment by  the  consideration  that  in  twenty-one  cases  it  was  suspended, 
which  is  as  great  a  number  as  resisted  treatment. 

It  is  also  a  noticeable  fact  that  some  of  the  cases  in  which  the  treat- 
ment was  suspended  were  very  much  benefited  by  it. 

I  have  no  doubt  that  man}^  more  cases  of  fibrous  tumors  of  the 
uterus  treated  by  ergot  might  have  been  collected  had  time  permitted, 
as  I  have  heard  of  cases  the  history  of  which  I  could  not  obtain. 

In  collating  my  cases,  I  have  in  no  way  selected  or  arranged  them 
to  influence  inferences  as  to  results,  but  I  have  faithfully  recorded  all 
I  have  received  from  correspondents,  or  found  in  journals,  which 
were  given  sufficiently  in  detail  to  enable  me  to  arrive  at  a  correct 
idea  of  the  treatment  and  its  effect. 


41 


642 


PIBEOTJS   TUMOES    OF    THE    UTEEUS. 


Hildebrandt I  27 

Bengelsdorf [  4 

Ciirobak |  9 

Atthill I  3 

White j  14 

Goodrich |  1 

Howard |  2 

Jackson i  8 

Ether  idge 1 

Merriman 4 

Fisher 1 

Morris 1 

Buckingham 1 

Cowan 1 

Dean  '  2 

Wey 1 

Hodder 4 

Jukes 1 

AVarner 2 

Bvford 9 

Allen 1 

Thomson 3 

Russell '  1 

Total 101 


r-    S    "    iC 

S2gS 
E.S  c  o 


11 


22 


39 


19 


21 


"WTiile  I  could  add  to  the  numlDer  of  cases  contained  in  this  tahle, 
they  would  not  affect  the  deductions  from  it. 

Modes  of  using  Ergot. 

Not  much  uniformity  has  been  observed  by  the  writers  above  quoted 
in  the  manner  of  using  ergot. 

Drs.  Hildebrandt,  Bengelsdorf,  Chrobak,  Atthill,  and  Jackson  recom- 
mend, and  use  it  hypodermically. 

Drs.  White,  Jenks,  and  Howard  administer  it  hypodermically,  inter- 
nally by  the  stomach,  and  in  the  form  of  suppositories  in  the  vagina 
and  rectum. 

Some  of  the  arguments  in  favor  of  the  hypodermic  injections  are : 
1st.  It  acts  more  rapidly  and  with  more  certainty.  2d.  It  does  not 
produce  the  gastric  disturbances  sometimes  caused  by  ergot  when 
taken  internally.  3d.  It  can  be  administered  in  this  way  when  it  is 
entirely  impracticable  to  give  it  internally  on  account  of  the  great 
exhaustion  or  gastric  irritability  of  a  patient. 

The  main  objections  to  the  hypodermic  method  seem  to  be:  1st, 
the  pain  inflicted  by  the  needle;  and,  2d,  the  inflammation  and  sup- 
puration which  ensue. 

Dr.  Hildebrandt  has  met  Avith  but  one  case  where  the  pain  of  the 


MODES    OF   USING    ERGOT.  643 

puncture  was  an  objection  to  its  hypodermic  use.  With  regard  to 
abscesses  he  says :  "  I  am  sure  I  do  not  exaggerate  when  I  say  that 
up  to  the  present  time  I  have  myself  made  one  thousand  hypodermic 
injections  of  ergotin  for  various  purposes,  or  have  seen  them  made 
and  observed  their  results  in  the  clinical  wards  in  charge  of  my 
assistants."  And  he  then  adds  :  "  I  have  never  seen  an  abscess  fol- 
low the  injections  made  by  me  personally,  and  only  in  three  clinical 
cases  did  this  occur.  The  chief  reason  why  no  abscesses  formed 
among  the  large  number  of  other  injections  is  that  I  always  injected 
the  fluid  very  deep  into  the  subcutaneous  cellular  tissue — perhaps 
even  into  the  abdominal  muscles." 

Dr.  Atthill  met  with  this  difficulty  in  all  three  of  his  cases,  although 
he  also  injects  the  fluid  deep  into  the  tissues. 

Dr.  Chrobak  was  obliged  to  desist  from  treatment  on  this  account, 
in  four  out  of  his-  nine  cases. 

Dr.  Cowan  was  interrupted  in  his  case  by  the  formation  of  abscesses. 

Thus  it  will  be  seen  that  much  difficulty  is  experienced  by  many 
in  carrying  out  the  treatment. 

Dr.  Hildebrandt's  reason  does  not  seem  to  be  the  only  one  why 
practitioners  are  so  troubled  with  this  objection,  since  Dr.  Atthill  and 
others  have  also  injected  deeply.  As  far  as  I  can  judge,  very  few 
have  been  able,  even  by  the  most  careful  efforts,  to  achieve  the  same 
happy  results  in  this  respect  as  Dr.  Hildebrandt. 

Dr.  Hildebrandt,  and  also  Dr.  Atthill,  select  the  lower  part  of  the 
abdomen  as  the  part  in  which  to  make  the  injections. 

Dr.  Keating,  of  Philadelphia,  injects  just  posterior  to  the  great 
trochanter. 

Dr.  Jackson  selects  the  deltoid  region,  and  thinks  it  makes  but 
little  difference  where  the  insertion  is  made. 

Dr.  White,  of  Buffalo,  injects  over  the  abdomen,  into  the  cervix 
uteri,  and  into  the  substance  of  the  tumor  if  it  is  accessible,  and  has 
met  with  no  bad  results. 

Dr.  Wey  used  over  two  hundred  injections  in  the  abdominal  region 
above  the  pubes  in  one  case,  and  abscesses  occurred  in  the  seat  of  the 
puncture  as  often  as  once  in  eight  operations. 

Dr.  Dean  commenced  using  ergot  in  the  form  of  Squibb's  fluid 
extract  by  injecting  it  into  the  cavity  of  the  uterus  through  a  flexible 
catheter,  but  now  he  employs  the  solution  of  Squibb's  solid  extract 
dissolved  in  water — one  grain  to  five  minims.  Of  this  he  injects  from 
ten  to  fifteen  drops  into  the  substance  of  the  cervix  about  four  times 
a  month  or  once  a  week.  He  thinks  the  effects  are  more  prompt  and 
energetic  than  when  administered  hypodermically.  His  instrument 
consists  of  a  barrel  the  same  size  as  the  common  hypodermic  syringe 
and  a  tube  six  inches  long.  He  has  known  inflammation  and  sup- 
puration to  follow  but  once  in  his  whole  experience. 


644  FIBROUS   TUMORS    OF    THE    UTERUS. 

Different  Preparations. 

Believing  the  preparation  of  the  medicine  employed  had  much  to 
do  in  causing  the  irritation  thus  observed,  efforts  have  been  made  to 
find  some  form  that  would  not  produce  the  painful  results  thus  de- 
scribed. 

Hildebrandt  is  now  in  the  habit  of  using  Dr.  AVernich's  formula 
for  the  watery  extract  of  ergot,  and  Dr.  Munde  thinks  it  is  very  simi- 
lar to  the  preparation  made  by  Dr.  Squibb.  Dr.  Hildebrandt  added 
pure  glycerin  in  the  proportion  of  about  one  part  to  four  of  the  solu- 
tion, and  the  amount  of  the  injection  was  forty  minims.  This  con- 
tained a  little  over  two  grains  of  the  extract,  probably  representing 
ten  to  twelve  grains  of  the  crude  ergot. 

Most  American  practitioners  now  use  Dr.  Squibb's  preparation 
above  referred  to,  some  of  them  by  dissolving  it  in  pure  water,  while 
others  add  to  the  water  a  small  amount  of  pure  glycerin.  Dr.  Squibb 
recommends  a  solution  of  this  extract  as  follows :  Dissolve  two  hun- 
dred grains  of  the  extract  in  two  hundred  and  fifty  minims  of  water 
by  stirring ;  filter  the  solution  through  paper,  and  make  up  to  three 
hundred  minims  by  washing  the  residue  on  the  filter  with  a  little 
water.  Each  minim  of  this  solution  represents  six  grains  of  ergot  in 
powder.  Of  this  solution  from  ten  to  twenty  minims  are  injected 
once  daily,  or  once  in  two  days.  This  is  the  only  preparation  I  have 
used  in  hypodermic  injections,  and  I  believe  it  the  best  we  can  at 
present  procure. 

Dr.  Wey  properly  lays  great  stress  on  the  necessity  of  having  the 
solution  fresh,  believing  that  in  a  very  short  time  it  deteriorates,  and 
becomes  more  irritating  to  the  tissues.  He  says :  "  Ergot  thus  ad- 
ministered generally  produces  prompt  effects."  In  most  instances, 
in  half  an  hour  the  patient  experiences  painful  contractions  of  the 
uterus.  The  hand  applied  over  the  organ  at  once  recognizes  the  in- 
creased hardness  in  the  mass.  These  contractions  increase  in  severity 
for  the  first  two  hours,  and  then  continue  with  vigor  for  from  six  to 
ten  hours,  gradually  becoming  less  until  they  cease  entirely.  Some 
patients  suffer  so  much  from  these  pains  as  to  refuse  to  proceed  in 
the  treatment,  while  others  bear  them  without  much  inconvenience. 
We  do  not  always  observe  these  painful  effects  even  when  the  drug 
operates  very  beneficially.  Sometimes  the  hemorrhages  are  controlled, 
as  it  were,  insensibly,  and  the  tumor  slowly  decreases  in  size  without 
the  patient  experiencing  any  considerable  discomfort.  It  seems  highly 
probable,  from  the  statements  made  by  my  correspondents,  and  espe- 
cially Dr.  Wey,  as  well  as  my  own  o-bservations,  that  the  benefits  of 
the  remedy  are  produced  with  more  rapidity  in  the  early  part  of  the 
treatment. 

The  preparation  used  internally  more  frequently  than  any  other  is 


DIFFERENT    PEEPARATIOXS.  645 

the  fluid  extract,  either  alone  or  in  combination  with  belladonna. 
Each  minim  of  Squibb 's  fluid  extract  is  equal  to  one  grain  of  ergot. 
Some  recommend  that  it  be  given  in  doses  of  thirty  drops  three  or 
four  times  a  day.  Others  believe  that  it  should  be  given  in  larger 
doses  less  frequently  repeated,  as,  for  example,  one  drachm  once  or 
twice  in  twenty-four  hours.  It  is  efficacious  given  in  either  way,  but 
probably  more  so  in  the  larger  and  less  frequent  doses.  This  prepara- 
tion is  so  offensive,  and  causes  so  much  nausea  in  exceptional  instances, 
that  it  cannot  be  borne. 

Dr.  Squibb  claims  that  his  solid  extract  does  not  offend  the  stomach 
so  frequently  as  the  fluid  extract.  This  extract  may  be  used  in  pills 
coated  with  gelatin.  A  pill  of  five  grains  is  equal  to  twenty  grains  of 
the  crude  ergot,  and  may  be  administered  twice  or  three  times  daily. 
From  observation  of  the  effects  of  the  different  preparations,  I  am 
satisfied  that  this  is  altogether  the  most  efficient  and  agreeable  for 
internal  administration. 

A  suppository  for  the  rectum,  which,  in  Dr.  White's  practice,  acted 
satisfactorily,  may  be  comjDOsed  of  fifteen  grains  of  the  solid  extract, 
and  enough  gelatin  to  give  it  size  and  form.  I  have  no  doubt  of  the 
great  usefulness  of  this  method  of  administering  ergot. 

I  think  it  is  also  quite  certain  that  the  addition  of  belladonna  in 
some  cases  increases  the  curative  effects  of  ergot;  how  much,  I  am 
not  quite  sure.  Dr.  Goodrich,  who  reached  such  splendid  results, 
gave  the  fluid  extract  of  ergot  and  belladonna  together  throughout 
the  entire  treatment  of  his  case. 

From  what  has  been  said  it  may  be  inferred  that  hyiDodermic  in- 
jection, if  the  most  efficacious,  is  also  the  most  objectionable  method 
of  using  the  ergot,  and  that  in  many  cases  the  exhibition  of  it  in  this 
way  is  rendered  entirely  impracticable,  because  intolerable,  to  the 
patients. 

May  we  not  hope  for  great  improvement  still  in  the  pharmacy  of 
ergot  ?  Ergot  produces  many  good  effects  besides  reducing  the  size 
of  the  tumors  and  relief  of  hemorrhage.  I  have  seen,  and  some  of 
my  correspondents  mention,  great  functional  improvement  in  the 
more  important  organs.  Some  patients  are  relieved  by  it  of  obstinate 
constipation  ;  the  appetite  is  improved,  and  the  general  health  restored. 
This  remarkable  salutary  effect  is  obviously  due  to  its  action  on  the 
ganglionic  nervous  system.  In  exceptional  instances  ergot  has  very 
disagreeable  effects.  Dr.  Goodrich  mentions  inflammation  of  the 
uterus  as  one,  and  my  patients  often  complain  of  great  heat  and 
tenderness  in  the  uterine  region.  Hildebrandt  speaks  of  one  case  in 
which,  after  the  sixth  injection,  the  patient  complained  of  vertigo, 
imperfect  control  of  her  lower  extremities,  and  slight  spasms  of  the 
flexor  muscles  of  the  forearm.  Dr.  Wey  observed  severe  general 
nervous   perturbation   to   follow  its  use  in  one   instance.     And  Dr. 


646  FIBROUS   TUMORS    OF    THE    UTERUS. 

Morris's  iDatient  discontinued  treatment  because  of  the  terrible  and 
tumultuous  effects  upon  the  uterus. 

Dr.  E.  P.  Allen,  of  Athens,  Pennsylvania,  sends  me  the  report  of  a 
very  interesting  case  of  fibrous  tumor  treated  by  hypodermic  injec- 
tions of  ergot,  in  which  phlebitis  supervened.  A  condition  of  one 
limb  was  produced  precisely  similar  to  j)hlegmasia  alba  dolens,  and 
ran  its  protracted  course  to  a  favorable  termination.  Prior  to  the 
accident  the  tumor  had  very  much  decreased  in  size  ,  but,  after  the 
treatment  was  suspended,  and  during  the  course  of  the  phlegmasia, 
it  rapidly  increased  again,  and  the  hemorrhages  which  had  been  con- 
trolled returned.  After  trying  other  methods  of  treatment  without 
any  good  results,  he  and  his  patient  in  despair  were  driven  to  the  use 
of  ergot  again.  It  was  tried  internall}^  with  some  good  effects,  but  as 
the  remedy  thus  administered  disagreed  with  the  stomach,  it  was  again 
injected  hypodermically  with  rapid  improvement.  The  injections 
were  used  on  the  side  of  the  abdomen,  opposite  to  that  formerly 
affected  with  23hlebitis.  After  a  number  of  injections,  signs  of  in- 
flammation of  the  veins  Avere  again  observed,  and  the  sound  leg 
passed  through  all  the  stages  of  jjlilegmasia  that  had  been  observed 
in  the  first.  From  the  intelligent  observation  of  Dr.  Wey  and  others, 
we  may  fairly  conclude  that  it  is  not  improper  to  continue  the  use  of 
ergot  during  the  menstrual  flow.  I  can  also  add  my  testimony  as  to 
its  entire  harmlessness  when  given  during  that  periodical  flow. 

Auxiliary  Treatment. 

With  the  exception  of  Drs.  Goodrich  and  Howard,  all  the  writers 
and  correspondents  quoted  have  depended  exclusively  on  ergot  for 
the  removal  of  fibrous  tumors  of  the  uterus ;  in  fact,  the  treatment  has 
been  experimental,  and  had  for  its  object  the  solution  of  the  question 
suggested  by  the  publication  of  Hildebrandt's  articles  on  the  use  of 
ergot,  viz.:  Will  ergot  cure  fibrous  tumors  of  the  uterus?  The  course 
pursued  was  well  calculated  to,  and  I  think  did,  test  Hildebrandt's 
treatment  pretty  thoroughly,  but  it  is  doubtful  whether  this  exclusive- 
ness  is  the  best  practice.  The  well-known  alterative  and  sorbefacient 
medicines  have,  in  rare  instances,  been  credited  with  the  cure  of  these 
tumors  without  the  aid  of  ergot,  and  it  is  not  difficult  to  understand 
that  absorption  may  be  promoted  with  more  certainty  by  the  alkaline 
bromides  and  iodides,  where  the  vitality  of  the  tumor  is  first  impaired 
by  the  action  of  ergot  on  its  vessels  and  the  muscular  fibres  surround- 
ing it.  Dr.  Goodrich  seems  to  have  held  this  view  of  the  alterative 
treatment,  as  he  prescribed  iodide  of  potassium  and  bichloride  of 
mercury  with  ergot.  Dr.  Howard  also  employed  alteratives  in  the 
same  way.  Both  of  these  gentlemen  combined  belladonna  with 
ergot.  The  efficiency  of  this  combination,  as  represented  by  their 
reports,  justifies  us  in  believing  that  the  alteratives  employed  by  them 


CORRECTIVE   TREATMENT —MODUS   OPERANDI.  647 

were  auxiliary  in  a  high  degree.  How  much  may  be  effected  by  ju- 
dicious alterative  and  other  auxiliary  treatment  will,  doubtless,  be 
determined  by  future  observation. 

Corrective  Treatment. 

By  this  I  mean  treatment  that  will  prevent  or  ameliorate  the  dis- 
agreeable effects  of  ergot  in  certain  exceptional  instances.  The  dis- 
tressing pain  caused  by  it  may  sometimes  be  made  more  tolerable  by 
the  administration  of  hydrate  of  chloral,  without  very  materially  in- 
fluencing its  other  effects.  Indigestion,  constipation,  hydrgemia,  and 
nervous  debility  may  be  corrected  by  tonics,  alteratives,  laxatives,  and 
stimulants  given  simultaneously  with  ergot.  In  short,  the  general 
condition  of  the  patient  should  be  cared  for  in  the  same  rational 
manner  as  if  ergot  was  not  being  administered. 

Modus  Operandi. 

The  influence  of  ergot  over  the  uterus  has  been  a  familiar  fact  to 
the  profession  for  a  long  time.  It  is  not  long,  however,  since  we  were 
aware  of  its  effects  upon  the  muscular  fibres  entering  into  the  forma- 
tion of  other  organs.  We  now  know  that  this  medicine  acts  upon  the 
unstriped  muscular  fibre  wherever  found,  whether  in  the  viscera  or  in 
the  vessels  of  the  body. 

'  The  fibres  of  the  uterine  walls,  and  the  arteries  supplying  them 
with  blood,  both  belong  to  this  class ;  this  fact  in  the  formation  of  the 
uterus  renders  it  particularly  susceptible  to  the  action  of  ergot.  The 
drug  acts  upon  the  uterus  in  a  threefold  manner,  and  causes  a  dimin- 
ished flow  of  blood  to  the  morbid  as  well  as  healthy  tissues  in  the 
uterine  structure. 

1st.  The  calibre  of  the  arterial  tubes  is  diminished  by  the  contrac- 
tion of  the  muscular  fibres  which  enter  into  their  composition.  2d. 
The  arterioles  are  diminished  in  size  by  compression  from  the  con- 
traction of  the  uterine  muscular  fibres  which  surround  them.  3d. 
These  vessels  are  distorted  and  drawn  in  diverse  directions  by  both 
the  contraction  and  compression,  and  hence  are  rendered  less  fit  for 
sanguineous  conduits. 

Another  consideration  of  prime  importance  is  that,  under  the  influ- 
ence of  these  medicines,  the  nutrition  of  fibrous  tumors  is  interfered 
with,  not  only  from  diminution  of  blood  in  their  tissues,  but  also  from 
compression  of  their  substance  by  the  proper  fibres  of  the  uterus,  their 
trophic  energies  are  arrested,  and  are  therefore  made  more  susceptible 
to  the  process  of  disintegration  and  absorption. 

The  great  influence  exerted  by  ergot  over  the  circulation  of  the 
uterus  is  rendered  more  efficacious  in  the  removal  of  fibroid  tumors 
of  that  organ,  because  of  the  peculiar  organization  of  the  growths.     It 


648 


FIBROUS    TUMORS    OF    THE   UTERUS. 


is  now  pretty  well  understood  that  this  neoplasm  is  not  very  gener- 
ously supplied  with  arterial  blood,  and  that  its  supply  is  derived  from 
numerous  minute  vessels  instead  of  one  or  two  of  larger  calibre.  From 
these  circumstances  it  results  that  its  vitality  is  very  low,  its  circula- 
tion easily  disturbed,  and  consequently  its  nutrition  impaired. 

I  think  we  are  justified  from  observation  in  assuming  that  the  action 
of  ergot  may  be  graded  from  an  almost  imperceptible  to  a  very  intense 
degree.  Probably  the  first  degree  affects  the  vascular  supply ;  the 
second,  in  addition  to  this,  causes  so  much  contraction  as  to  merely 
render  the  fibres  tense  without  causing  pain  ;  and  the  third  prompts 
the  uterine  fibres  to  vigorous  and  painful  contraction. 

This  inference  is  ]3lainly  deducible,  I  think,  from  the  several  modes 
by  which  tumors  are  made  to  disappear  under  its  action,  as  well  as 
from  direct  observation  of  the  uterine  fibres. 

I  will  now  venture  to  call  attention  especially  to  the  manner  of  ex- 
pulsion of  the  polypoid  and  submucous  intramural  varieties.  It  will 
be  seen  from  Fig.  286  that  when  the  uterus  contracts,  all  the  fibres 


Fig.  286. 


Fibroid  Polypus. 


Submucous  Fibroid  Tumor. 


unite  in  pressing  the  polypus  through  the  cervical  canal,  which  is 
usually  already  shortened,  and  rendered  dilataljle  in  consequence  of 
its  increased  vascularity. 

The  cervical  canal  dilates,  and  after  more  or  less  painful  efforts  the 
polypus  is  expelled  entire,  covered  by  the  mucous  membrane.  This 
membrane  is  often  in  a  state  of  gangrene,  but  so  far  as  I  have  observed 
these  cases,  the  tumor  is  not  broken  to  pieces. 

Fig.  287  represents  an  intramural  fibroid  between  the  central  line 
of  the  uterine  wall  and  the  mucous  membrane.     It  is  intended  to 


MODUS    OPERANDI. 


649 


show  a  tumor  where  a  thin  layer  of  fibres  separate  it  from  the  mucous 
membrane,  and  how  a  thick  and  heavy  layer  is  spread  over  its  exter- 
nal hemisphere.  Three-quarters  of  the  thickness  of  the  muscular  wall 
are  applied  to  that  side  of  the  tumor.  If  in  this  position  all  the  fibres 
of  the  uterus  vigorously  contract,  the  fibres  near  the  mucous  mem- 
brane must  be  overcome  by  the  heavy  layer  outside  (at  c).  But  the 
opposite  wall  of  the  uterus  plays  an  important  part  by  supporting  the 
weaker  layer  at  the  fundus  of  the  tumor,  and  adding  its  own  force  in 
overcoming  the  capsule  (at  e),  where  it  usually  gives  wa3^  The  posi- 
tion of  the  tumor  makes  its  escape  from  the  concentric  action  of  all 
the  fibres  of  the  uterus  impossible,  and  every  one  knows  that  when 


Fig.  288. 


Sub-peritoneal  Fibroid  Tumor. 

the  resistance  is  partially  overcome,  the  uterus  is  stimulated  to  more 
vigorous  action,  and  the  pains  will  not  abate  until  the  mass  is  ex- 
pelled. If  not  too  large,  it  is  driven  out  without  undergoing  great 
laceration,  but  if  its  size  and  attachments  are  such  as  to  make  this 
impracticable,  it  will  be  broken  into  fragments  and  expelled  piece- 
meal. 

Allow  me  to  supplement  the  above  description  by  explaining  the 
effect  of  ergot  on  the  sub-peritoneal  and  central  intramural  tumor. 
In  Fig.  288  we  see  the  disposition  of  the  fibres  on  the  sub-peritoneal 
variety  ;  next  the  uterine  cavity  there  is  a  thick  and  strong  stratum 
of  fibres,  while  immediately  under  the  peritoneum  the  layer  is  very 
thin  and  comparatively  weak.     When  the  uterus  is  acting  with  vigor, 


650  FIBEOUS    TUMOES    OF   THE    UTERUS. 

the  fibres  between  A  and  B  will  cause  those  two  pomts  to  approxi- 
mate each  other,  and  the  tumor  will  become  pediculated ;  but  that  is 
all,  for  the  tumor  lays  outside  the  field  of  concentric  action  and  escapes 
the  crushing  infiuence  to  which  the  submucous  variety  is  subjected. 
The  amount  of  force  exerted  upon  it  is  that  exercised  by  the  weaker 
laj^er  of  fibres  in  a  state  of  conquered  antagonism,  and  the  rupture  of 
the  capsule  is  impossible. 

If  we  take  Fig.  289  as  a  correct  representation  of  the  fibrous  tumor 
when  situated  in  the  central  stratum  of  fibres,  in  which  the  antago- 
nism is  equal  at  all  points,  it  will  be  evident  that  there  is  no  ten- 
dency to  rupture  of  the  capsule,  and  much  less  crushing  influence 
exerted  upon  it  than  if  it  were  situated  slightly  nearer  the  mucous 
membrane. 

Fig.  289. 


Intramural  Fibroid  Tumor. 

This  variety  of  the  tumor,  therefore,  yields  to  the  influence  of  ergot, 
only  as  it  may  be  "  starved  out "  by  diminution  of  its  blood  supply, 
and  as  the  eff"ect  of  pressure,  which  we  all  know  are  the  two  conditions 
most  favorable  to  absorption. 

Now  I  think  we  have  arrived  at  a  point  in  this  investigation  where 
we  can  draw  inferences  as  to  the  forms  of  tumors  likely  to  be  aff'ected 
by  ergot  in  different  ways,  as  well  as  those  that  will  not  be  afi'ected 
by  it. 

We  do  not  expect  ergot  to  cause  painful  and  efficient  contractions 
in  the  healthy  unimpregnated  uterus ;  its  fibres  are  not  capable  of 
such  contraction,  and  it  is  not  until  the  fibres  have  become  greatly 
developed  that  they  are  susceptible  to  the  impressions  of  ergot.  In 
cases  of  early  abortion,  its  action  is  very  unreliable,  but  after  the 
fourth  month  of  pregnancy  it  acts  quite  efficiently. 

In  tumors  of  the  uterus,  the  development  of  the  fibrous  structure 


MODUS    OPEEANDI.  651 

is  sometimes  so  slight  that  it  is  incapable  of  contraction ;  there  may 
be  so  many  nuclei  of  degeneration  that  there  are  not  enough  sound 
fibres  left  for  efficient  contraction.  Then,  where  there  are  many 
small  tumors  developed  in  the  uterine  walls,  the  circulation  is  cut  off 
to  such  a  degree  that  they  degenerate  into  a  cartilaginoid  substance, 
and  sometimes  they  are  infiltrated  with  calcareous  material.  In  none 
of  these  cases  will  ergot  cause  any  appreciable  results.  When,  how- 
ever, there  are  but  one,  two,  or  three  nuclei  of  morbid  growths,  as 
they  increase  in  size  the  fibres  undergo  the  development  necessary  to 
enable  them  to  contract  with  great  efficiency,  and  render  them  sus- 
ceptible to  the  influence  of  ergot. 

Another  condition  which  influences  the  hypertrophic  growth  of  the 
fibres  is  the  situation  of  the  tumor. 

Subperitoneal  tumors  do  not  cause  as  great  growth  in  the  fibres  of 
their  neighborhood  as  the  intramural  or  submucous  varieties.  A 
single  intramural  tumor  causes  great  development  of  the  whole  uterine 
tissues,  but  the  development  of  the  wall  in  which  it  is  situated  de- 
cidedly predominates.  The  submucous  neoplasm  so  soon  gains  the 
uterine  cavity  that  the  development  is  nearly  the  same  in  the  whole 
organ. 

When,  therefore,  we  administer  ergot  for  the  cure  of  fibrous  tumors 
of  the  uterus,  the  beneficial  action  of  the  drug  will  depend  upon  the 
degree  of  development  of  the  fibres  of  the  uterus,  and  the  position  of 
the  tumor  with  reference  to  the  serous  or  mucous  surface.  The  nearer 
the  mucous  surface,  the  better  the  effects.  If  the  tumor  is  very  near 
the  lining  membrane,  we  may  hope  for  its  expulsion  en  masse,  or  by 
disintegration. 

We  can  often  select  the  cases  in  which  good  results  may  be  expected. 
There  are  four  conditions  which  are  usually  reliable  for  this  purpose. 
They  are:  smoothness  of  contour,  hemorrhage,  lengthened  uterine 
cavity,  and  elasticity.  A  smooth,  round  tumor  denotes,  for  the  most 
part,  uniform  textural  development,  hemorrhage,  a  certain  proximity 
to  the  mucous  membrane,  a  lengthened  cavity,  great  increase  in  the 
length  and  strength  of  the  fibres ;  and  elasticity  assures  us  of  the  fact 
that  cartilaginoid  or  calcareous  degeneration  has  not  begun  in  the 
tumor. 

An  uneven,  nodulated  tumor  may  be  composed  of  many  separate 
solid  masses.  These  displace  and  prevent  the  growth  of  the  fibres  to 
such  an  extent  as  to  render  contractions  inefficient.  When  hemor- 
rhage is  not  present,  the  tumor  is  probably  near  the  serous  surface, 
and  consequently  not  surrounded  by  fibres.  A  short  cavit.y  denotes 
short,  undeveloped  fibres,  while  hardness  is  indicative  of  unimpress- 
ible  induration. 

Although  I  have  no  experience  in  the  use  of  ergot  in  such  cases,  I 
should  expect  large  fibro-cystic  tumors  to  resist  its  action. 


652  FIBROUS   TUMORS    OF   THE    UTERUS. 

From  this  view  of  the  subject,  it  will  be  seen  that  I  freely  admit  that 
there  is  a  large  number  of  cases  in  which  ergot  cannot  produce  any 
good  results  in  consequence  of  their  nature.  Another  reason  of  equal 
moment  why  ergot  may  fail  to  act  upon  such  cases  as  would  seem  to 
be  favorable,  is  the  worthlessness  of  the  drug  and  its  preparations. 

Dr.  Squibb,  of  New  York,  a  high  authority,  says  in  reference  to  this 
subject: 

"The  molecular  constitution  of  the  active  portion  of  the  drug  seems,  however,  in  its 
natural  condition  to  be  loose,  and,  like  a  slow  fermentation,  to  be  undergoing  slow 
molecular  changes,  so  that  by  age  its  peculiar  activity  is  slowly  diminished  until 
finally  lost." 

And  again : 

"The  ergot  in  the  grain,  however  well  kept,  is  known  to  become  inactive  without 
any  known  change  in  appearance,  though  the  sensible  properties,  such  as  odor  and 
taste,  may  and  probably  do  not  change.  Ergot,  in  powder,  is  known  to  diminish  in 
activity  much  more  rapidly  than  when  in  grain,  and  probably  soon  becomes  inert.  The 
tincture  and  wine  of  ergot  are  believed  to  cliange,  though  more  slowly  than  the  ergot 
in  substance  ;  while  the  extracts,  and  so-called  ergotins,  are  all  supposed  to  change 
more  rapidly." 

These  facts,  so  explicitly  stated  by  Dr.  Squibb,  are  very  sugges- 
tive as  to  the  causes  of  the  frequent  failures  of  ergot,  and  need  no 
comment. 

When  all  these  causes  of  failure  are  considered,  the  variety  of  ex- 
perience met  with  in  the  reports  upon  its  trial  in  the  treatment  of 
these  tumors  is  not  surjorising.  It  should  not,  however,  be  discour- 
aging, but  should  prompt  us  to  more  care  in  selecting  the  cases  and 
securing  reliable  preparations  of  ergot.  I  have  implicit  faith  in  the 
action  of  ergot  when  all  the  conditions  I  have  pointed  out  are  present. 
I  do  not  believe  it  to  be  uncertain  in  its  action. 

In  addition  to  the  above  conditions,  I  believe  perseverance  an  in- 
dispensable condition  to  success,  as  it  often  requires  several  months 
to  get  the  best  results. 

In  concluding,  I  desire  to  disclaim  any  expectation  that  ergot  will 
supplant  other  modes  of  treatment.  The  expert  surgeon  will,  as  he 
always  has,  use  his  instruments  to  the  neglect  of  remedies  less  sum- 
mary in  their  effects,  and  in  his  hands  the  maximum  of  safety  will 
obtain ;  but  there  are  very  few  general  practitioners  who  ought,  or 
would  be  willing,  to  undertake  enucleation  of  fibroid  tumors  of  the 
uterus.  I  do  claim,  however,  that  the  judicious  gynecologist  will 
lose  fewer  patients,  and  make  more  cures,  by  the  consistent  adminis- 
tration of  this  medicine  than  can  be  looked  for  from  surgery. 

I  am  surprised  that  others  who  have  written  upon  the  subject 
should  be  so  incredulous  as  to  the  effect  of  ergot,  and  the  only  way 
I  can  account  for  it  is  what,  I  think,  I  can  see  in  their  practice  as 


MODUS   OPERANDI.  653 

related  by  themselves,  viz.,  that  they  do  not  give  it  a  fair  trial.  They 
fail  to  give  it  in  large  enough  doses  and  persevere  long  enough  in  its 
use.  The  treatment  of  some  of  my  successful  cases  extended  over 
many  months.  When  the  pains  that  indicate  efficient  action,  and 
always  precede  disruption  and  expulsion  occur,  the  practitioner  gen- 
erally becomes  alarmed,  gives  anodynes,  and  withdraws  the  medicine, 
thus  abandoning  the  case,  and  declaring  that  ergot  is  a  dangerous 
remedy.  If  he  had  witnessed  the  same,  or  even  severer,  pains  in 
labor,  he  would  have  encouraged  them,  and  so  he  should  do  in  ex- 
pelling the  tumor,  and  the  result  would  be  a  safe  delivery.  The 
tumor  would  be  expelled  and  the  patient  relieved. 

Before  drawing  my  remarks  on  the  use  of  ergot  to  a  close  allow 
me  to  mention  some  of  the  queries  that  have  arisen  in  my  own  mind, 
or  have  been  propounded  to  me  by  medical  men.  If  the  ergot  acts 
so  powerfully  in  expelling  submucous  tumors,  is  there  not  danger  that 
it  may  rupture  the  capsule  of  the  subserous  variety,  thus  expelling 
them  from  the  uterine  substance  into  the  peritoneal  cavity,  and  en- 
danger the  life  of  the  patient  by  causing  peritonitis  ?  A  proper  con- 
sideration of  the  conditions  existing  in  such  cases  will  justify  my 
answering  this  query  in  the  negative.  There  is  a  great  difference  in 
the  influence  exerted  by  the  uterine  fibres  on  the  two  varieties  of 
tumors.  In  the  submucous  variety  the  whole  power  of  the  uterine 
contractions  is  exerted  toward  the  tumor,  driving  it  in  the  direction 
of  the  OS  uteri.  When  the  tumor  is  subserous  the  contractions  are 
from  the  axis  of  the  tumor,  and  their  effect  is  merely  to  render  it 
pedunculated,  and  lessen  the  vascular  supply  going  to  it.  The  main 
effect,  therefore,  will  be  to  check  the  rapidity  of  its  growth,  or  to 
prevent  its  further  enlargement  altogether.  This  statement  will  suffi- 
ciently explain  the  effects  of  the  medicine  upon  this  variety  of  these 
morbid  growths.  Another  question  is,  does  the  long-continued  ad- 
ministration of  ergot  induce  the  gangrene  of  the  extremities,  that  has 
been  attributed  to  it  ?  And  still  another,  does  it  cause  inconvenience 
or  danger  by  affecting  seriously  the  nervous  centres  ?  After  having 
given  this  remedy  in  frequently  repeated  and  large  doses,  and  ob- 
served its  effects  with  great  care  for  a  number  of  months  consecu- 
tively, I  can  say  that  I  have  not  noticed  any  such  consequences.  I 
am  not  prepared  to  assert  that  there  is,  and  always  will  be,  immunity 
from  such  effects.  The  worst  symptoms  I  have  witnessed  are  the 
severe  and  persistent  pains,  and  the  apparent  inflammation  of  the 
uterus  and  peritoneum,  where  its  action  has  been  excessive.  These 
symptoms,  however,  have  been  invariably  controlled  by  proper  treat- 
ment, and  have  in  no  instance  proved  disastrous.  In  other  cases, 
when  the  tumor  was  slowly  disintegrated  and  expelled,  a  moderate 
form  of  septicaemia  has  invariably  occurred ;  but  this  condition  has 
not  been  sufficiently  grave  to  excite  alarm  in  my  mind. 


654  FIBROUS   TUMORS   OF    THE   UTERUS. 

A  simultaneous  employment  of  sorbefacients  and  the  administra- 
tion of  ergot  would,  doubtless,  in  some  cases  prove  more  efficacious 
than  either  alone.  But  I  am  free  to  confess  that  this  conclusion,  so 
far  as  I  am  concerned,  is  arrived  at  more  from  therapeutic  inference 
than  observation.  As  I  am  giving  the  results  of  my  own  observation, 
more  than  those  derived  from  the  research  of  others,  I  deem  it  but 
fair  to  state  that  I  have  not  given  this  combined  method  of  treatment 
an  extensive  trial. 

We  should  remember,  in  the  employment  of  any  course  of  treat- 
ment for  the  cure  of  these  fibrous  tumors,  that  reliable  results  are  not 
to  be  obtained  without  the  long-continued  use  of  the  remedies,  and  a 
thoughtful  management  of  them  in  individual  cases.  And  I  must 
say,  in  this  connection,  that  I  believe  a  want  of  these  considerations 
has  led  to  much  false  experience.  The  treatment  of  fibrous  tumors, 
located  in  other  organs  than  the  uterus,  will  not  serve  as  a  useful 
guide  in  the  management  of  the  uterine  neoplasm.  The  same  con- 
ditions do  not  exist  elsewhere.  The  tumors  are  nowhere  else  sur- 
rounded with  muscular  fibres  whose  action  can  be  commanded  by  any 
remedy  within  our  knowledge.  Whether  the  observation  of  the  pro- 
fession at  large  will  or  will  not  at  present  bear  me  out  in  my  earnest 
belief  in  the  curability  of  some  of  these  tumors  by  the  means  I  am 
now  teaching,  I  do  not  know ;  but  I  am  sure  that  there  is  so  much 
logic  in  the  method  that  it  deserves  a  much  more  extensive  trial  than 
has  hitherto  been  made  of  it. 

Treatment  by  Electricity. 

Recently  the  treatment  of  uterine  myomata  by  electrolysis  has  re- 
ceived considerable  attention.  The  pioneers  of  this  method  were  Drs. 
Cutter,  Kimball,  and  Brown.  At  a  meeting  of  the  American  Medical 
Association  in  this  city,  Dr.  Cutter  illustrated  his  method  of  operat- 
ing. He  uses  electrodes  invented  especially  for  this  purpose.  They 
are  spear-shaped  and  mounted  upon  handles,  in  order  that  they  may 
be  directed  with  the  more  certainty,  and  made  to  penetrate  hard, 
fibrous  growths  without  deviating  from  their  intended  course.  The 
blades  are  five  and  one-half  inches  long,  and  are  insulated  to  within 
nearly  one  inch  of  the  point.  Two  of  these  electrodes  are  inserted 
through  the  abdominal  wall  into  the  substance  of  the  tumor,  the 
points  being  separated  by  a  space  of  several  inches.  Through  these 
electrodes  a  galvanic  current  is  passed,  the  electricity  being  generated 
by  eight  pairs  of  carbon  and  zinc  plates,  excited  by  saturated  solu- 
tion of  potassic  bichromate  and  sulphuric  acid,  one  part  of  the  former 
to  two  of  the  latter.  The  time  allowed  at  each  sitting  varies  from 
three  to  fifteen  minutes.  It  was  said  that  this  operation  did  not  pro- 
duce much  pain,  and  was  usually  followed  by  a  copious  flow  of  urine. 


TREATMENT    BY    ELECTRICITY.  655 

The  number  of  operations  for  the  individual  cases  varied  from  one 
to  nineteen,  and  the  intervals  between  them  from  a  day  to  two  months. 
In  certain  desperate  cases  this  seems  to  me  to  be  a  valuable  resource. 

ApostoWs  Method. 

In  1882  Apostoli*  began  using  electricity  for  these  tumors  in  a 
somewhat  different  but  apparently  no  less  efficacious  manner.  In- 
stead of  puncturing  the  abdominal  walls,  he  places  one  pole  over  the 
abdomen  and  another  within  the  uterus.  When  the  uterus  cannot  be 
sounded  he  punctures  the  tumor  either  from  the  vagina  or  from  the 
highest  available  point  in  the  cervical  or  uterine  cavity.  The  external 
electrode  is  made  of  a  thin  layer  of  wet  potters'  earth  spread  over  the  ab- 
domen so  as  to  lie  in  intimate  contact  with  the  skin  over  a  surface  about 
twelve  inches  in  diameter.  This  enables  him  to  use  a  current  of  100 
milliamperes  without  harm  or  inconvenience  to  the  patient.  In  1887 
Dr.  F.  H.  Martin,t  of  Chicago,  constructed  an  abdominal  electrode  of 
animal  membrane  with  which  he  has  used  300  to  400  milliamperes. 

The  internal  or  active  electrode  is  the  isolated  end  of  a  platinum  or 
gold  sound,  and  acts  upon  the  entire  length  of  the  uterine  cavity,  or 
upon  the  canal  made  in  the  substance  of  the  tumor  by  a  sharp-pointed 
electrode.  He  employs  as  strong  a  current  as  the  patient  can  bear 
without  discomfort,  and  continues  it  from  one  or  two  minutes  to 
twenty,  or  an  average  of  five  to  ten,  and  maintains  that  a  mild  current 
of  longer  duration  does  not  have  the  same  eff'ect.  With  these  large 
external  electrodes  the  strength  of  the  current  is  determined  by  the 
eff'ect  produced  at  the  internal.  From  100  to  150  milliamperes  is  the 
maximum  intensity  that  can  be  tolerated  with  an  ordinary  internal 
electrode  about  three  inches  in  length.  When  the  internal  electrode 
can  be  made  longer  or  larger  the  intensity  may  be  made  still  greater. 
In  all  cases  it  is,  however,  necessary  to  commence  with  a  mild  current 
and  increase  its  strength  gradually. 

The  treatment  is  continued  until  the  patient  is  relieved  of  all 
symptoms  referable  to  the  tumor,  and  sometimes  longer.  The  average 
number  of  treatments  is  from  twenty  to  thirty,  although  sometimes 
not  half  that  many,  sometimes  many  more,  may  be  required.  The 
removal  of  large  tumors  is  not  usually  attempted  after  the  symptoms 
are  relieved,  as  that  requires  more  time  than  the  patient,  and  probably 
the  physician,  cares  to  spend  in  the  trial.  Nevertheless,  some  of  the 
small  ones  have  disappeared  and  many  large  ones  have  become 
smaller. 

The  best  time  for  the  application  is  between  the  menstrual  periods 

*  Traitement  Electrique  des  Turueurs  Fibreuses  de  I'Uterus,  L.  Carlet. 
f  Treatment  of  Fibroid  Tumors  by  Electrolysis.     Jour.  Am.  Med.  Ass'n,  April 
23,  1887. 


656  FIBROUS    TUMORS    OP   THE    UTERUS. 

and  while  the  uterus  is  not  bleeding,  although  Apostoli  sometimes 
makes  them  for  the  purpose  of  checking  existing  hemorrhage. 

Modes  of  Action, 

It  is  difficult  to  determine  just  how  electricity  acts  in  these  cases, 
but  it  jDrobably  acts  in  several  different  ways.  The  fact  that  the 
tumors  are  of  a  low  grade  of  vitality,  and  that  they  are  surrounded  by 
muscular  tissue  easily  brought  into  action,  renders  them  subject  to  an 
arrest  of  growth  from  comparatively  slight  causes.  Their  intimate 
connection  with  the  nutritive  changes  of  the  uterus  also  has  much  to 
do  with  their  growth  and  decay. 

The  following  are  perhaps  the  principal  kinds  of  action  produced 
by  the  electricity : 

1.  The  excitement  of  inflammation  in  the  substance  of  the  tumor,  interfer- 
ing with  its  nutrition  and  producing  absorption  of  its  degenerated 
elements.  This  is  probably  the  manner  in  which  the  applications 
formerly  made  by  Cutter,  Brown,  Kimball,  T.  G.  Thomas,  Baker,  and 
their  followers,  act. 

2.  The  electric  current  is  supposed,  in  these  low  forms  of  tumor,  to 
have  an  electrolytic  action^  breaking  up  the  chemical  combinations  so 
that  the  acids  accumulate  about  the  positive  pole  and  the  bases  about 
the  negative,  and  are  thus  cast  off  and  absorbed.  Just  how  this  can 
occur  to  any  considerable  depth  in  living  tissue  without  destroying 
its  life  along  the  course  of  the  current,  any  more  than  the  stomach  can 
digest  itself,  would,  however,  seem  incomprehensible. 

3.  A  chemical  or  caustic  action  is,  however,  more  easily  understood, 
and  is  one  of  the  most  important  factors  in  Apostoli's  method.  His 
observations  go  to  show  that  when  the  external  electrode  is  connected 
with  the  positive  pole  the  hemorrhage  may  be  checked.  The  tissues 
are  cauterized  and  hardened  in  much  the  same  way  as  if  they  had 
been  seared  by  the  actual  cautery  at  a  low  heat.  In  cases  of  subperi- 
toneal fibroids  without  hemorrhage  he  connects  the  negative  pole  with 
the  uterine  sound  and  produces  sloughing  and  hemorrhage,  and  thus 
claims  to  deplete  them.  As  the  explanations  are  entirely  theoretical, 
it  is,  I  think,  as  reasonable  to  suppose  that  the  negative  pole  checks 
the  hemorrhage  by  simple,  moderate  but  deep  cauterization  and  subse- 
quent cicatrization,  and  that  the  positive  pole  diminishes  the  nutrition 
of  the  subperitoneal  tumors  by  cauterizing  and  cicatrizing  the  uterine 
walls  about  their  bases  or  pedicles. 

4.  Electricity  also  acts  as  a  poucrful  stimulant  to  uterine  contraction, 
and  may  do  so  both  during  and  after  the  treatment  without  causing 
pain.  Such  painless  contraction  occurs  after  labor,  abortion  or  mod- 
erate uterine  dilatation.  That  this  contraction  diminishes  the  vitality 
of  the  tumor  there  is  little  doubt,  although  it  may  play  but  a  sub- 


TREATMENT    BY    ELECTRICITY.  657 

ordinate  part  in  the  treatment  by  electricity.     The  cauterization  also 
acts  as  a  stimulant  to  contraction  in  the  uterine  walls. 

5.  A  local  alterative  or  atrophizing  influence  must  also  be  attributed  to 
this  treatment.  The  disturbance  of  such  a  powerful  electric  current 
to  the  organic  nerves,  and  to  the  vitality  of  the  cell  structure,  must 
have  a  decided,  albeit  a  secondary  or  adjuvant  action. 

Dangers  Attending  its  Use. 

The  dangers  of  this  treatment  are  great  unless  the  operator  is  thor- 
oughly competent  and  extremely  careful.  However,  a  minute  study 
of  the  technique  as  taught  by  Apostoli  renders  his  method  a  perfectly 
safe  one  to  emplby.  But  the  puncture  of  the  tumor  from  the  abdo- 
men must  always  be  attended  by  some  danger,  and  also  requires  the 
use  of  an  ansesthetic. 

Carelessness  in  the  introduction  or  isolation  of  the  probe,  or  in 
making  the  puncture  per  vaginam,  may  lead  to  disagreeable  or  serious 
consequences.  Sudden  interruptions  in  a  powerful  current  would 
cause  serious  shock,  as  might  also  a  sudden  increase  in  its  intensity. 
Severe  exertions,  exposure,  venereal  indulgence,  etc.,  after  a  treatment 
must  also  be  guarded  against  among  the  careless  and  less  intelligent 
patients. 


42 


CHAPTEE    XL. 

SURGICAL  TREATMENT. 

Removal  of  Polypoid  Tumors. 

The  first  thing  I  have  to  say  about  the  operations  intended  for 
this  purpose  is  that  they  should  be  as  simple  as  possible,  compatible 
with  thoroughness.  It  is  not  necessary  to  exemplify  this  idea.  It 
is  self-evident,  and  yet  often  ignored.  The  most  effectual  plan  of 
avoiding  danger  is  to  have  a  distinct  idea  of  the  sources  whence  the 
danger  may  arise,  and  in  connection  with  these  tumors  dangers  may 
arise  (1)  from  laceration,  contusion,  or  other  damage  to  the  uterus, 
resulting  in  hemorrhage  or  inflammation ;  (2)  incomplete  ablation, — 
the  remaining  portion  producing  septicaemia;  (3)  shock  sometimes 
following  protracted  efforts  at  removal.  This  last  is  a  very  important 
source  of  peril. 

These  dangers  will,  therefore,  for  the  most  part  be  proportionate 
to  the  extent  of  manipulation  and  instrumental  procedure  and  the 
incompleteness  of  the  operation.  The  old  operation  of  tying  the  neck 
of  the  tumor,  and  allowing  it  to  slough  away,  especially  when  it  was 
situated  in  the  uterine  cavity,  combined  all  the  causes  of  danger  above 
enumerated  except  that  arising  from  hemorrhage ;  and  it  is  a  curious 
fact  that  this  operation  was  invented  for  the  sole  purpose  of  avoiding 
hemorrhage,  which  is  really  the  least  dangerous  of  all,  according  to 
my  observation.  Indeed,  I  have  never  seen  serious  hemorrhage 
caused  by  the  removal  of  a  polypus  however  effected.  The  practice 
of  ligating  the  tumor  and  then  amputating  it  is  to  a  less  degree  open 
to  the  same  criticism. 

Torsion  or  amputation  are  the  methods  now  usually  employed  by 
the  best  gynecological  surgeons  of  the  present  day,  and  the  first  is 
the  one  I  have  for  several  years  resorted  to  in  almost  every  instance. 
Amputation  may  be  performed  by  the  scissors,  knife,  by  the  ecraseur, 
or  galvano-cautery  wire.  All  possible  danger  from  hemorrhage  will 
be  avoided  by  the  last  means  indicated ;  but  I  may  state  that  there 
is  scarcely  any  danger  of  hemorrhage  from  the  use  of  either  of  the 
other  instruments.  Torsion  is  performed  by  seizing  the  tumor  with 
strong  vulsellum  or  fenestrated  forceps  and  twisting  the  tumor  several 
times  around  and  making  moderate  traction  until  the  detachment 
and  removal  are  completed.  In  order  to  amputate  a  polypus  when 
the  tumor  is  partially  or  wholly  expelled  from  the  uterus  the  tumor 
should  be  drawn  down  with  one  of  the  forcejDS  mentioned  until  its 


EEMOVAL  OF  POLYPOID  TUMOES.  659 

attachment  is  brought  into  view,  when  with  the  scissors  or  the  knife 
the  neck  may  be  divided  as  close  to  the  uterine  attachment  as  possible 
without  cutting  the  substance  of  the  uterus  ;  or  the  neck  of  the  tumor 
may  be  surrounded  by  the  6craseur  or  galvano-cautery  wire  and  sepa- 
rated by  it.  A  tumor  attached  to  the  fundus,  or  high  up  in  the  body 
of  the  uterus,  cannot  always  be  drawn  down  and  amputated  in  this 
way  without  causing  inversion  of  the  organ,  and  consequently  a  knife 
in  the  shape  of  the  blunt  hook  in  our  obstetric  case,  with  an  edge 
upon  the  concavity  of  the  curve,  will  be  necessary.  This  may  be  in- 
troduced and  guided  as  nearly  as  possible  to  the  j)oint  of  attachment 
by  the  finger  or  hand.  This  process  is  very  much  facilitated  by  a 
piece  of  twine  passed  through  a  small  hole  in  the  extremity  of  the 
hook  ;  the  twine  should  be  long  enough  to  hang  out  of  the  vagina  and 
give  a  firm  hold.  When  placed,  the  convexity  of  this  knife  should  be 
turned  towards  the  neck  of  the  tumor  and  a  sawing  motion  executed 
by  the  handle  and  twine  until  the  tumor  is  cut  through. 

The  chain  of  an  ecraseur  may  be  carried  to  or  near  the  point  of 
attachment  by  means  of  two  flexible  rods  with  small  holes  in  the  ex- 
tremities. The  wire  is  passed  through  the  opening  at  the  ends  of  the 
rods,  and  being  held  closely  together  they  are  introduced,  carried 
behind  the  polypus,  as  high  up  as  possible.  One  of  the  rods  is  then 
held  in  position  while  the  other  is  carried  around  the  tumor,  thus  en- 
circling it  by  the  wire.  Sometimes  it  will  be  easy  to  pass  the  wire  by 
drawing  a  loop  of  it  through  the  perforated  ends  of  the  rods,  large 
enough  to  pass  entirely  around  the  lower  end  of  the  tumor,  and  as 
the  rod  ascends,  the  wire  surrounding  the  polypus  is  carried  up  to 
the  point  of  attachment.  When  well  placed,  the  ends  of  the  wire 
may  be  fitted  to  the  ecraseur,  and  that  instrument  carried  up  to  the 
ends  of  the  rods.  The  ecraseur  can  then  be  manipulated  until  the 
tumor  is  separated.  There  is  no  need  of  removing  the  rods  from  the 
wire  before  the  ecraseur  is  fixed,  as  their  presence  does  not  complicate 
the  operation. 

All  this  explanation  presupposes  an  open  or  dilatable  condition  of 
the  OS  uteri  which  does  not  always  exist.  If  the  mouth  of  the  uterus 
is  not  already  thus  patent,  it  should  be  dilated  by  compressed  sponges 
until  it  will  admit  of  free  access. 

It  requires  much  experience  and  tact  to  perform  this  operation 
with  the  6craseur,  and  we  will  find  in  the  books  and  periodicals  a 
number  of  instruments  intended  to  facilitate  the  application  of  the 
wire  to  the  neck  of  the  tumor.  The  dangers  connected  with  this 
operation  are  those  caused  by  the  protracted  efforts  to  replace  the 
chain  or  wire  of  the  ecraseur,  and  an  inability  always  to  remove  the 
whole  tumor. 

The  operation  of  torsion  can  be  performed  when  the  tumor  wholly 
or  partly  occupies  the  vagina  without  any  preparation,  and  is  prefer- 


660 


SUEGICAL  TREATMENT. 


Fig.  290 


able,  because  the  tumor  is  removed  at  the  point  of  attachment.  The 
reason  of  this  is,  the  point  of  attachment  is  always 
the  weakest,  and  yields  to  the  force  applied  before 
any  violence  occurs  to  the  other  parts  of  the  tumor 
or  the  uterine  tissue.  The  tumor  is  thus  com- 
pletely removed,  and  without  protracted  manipu- 
lation. No  hemorrhage  results  for  two  reasons :  1, 
there  are  no  large  vessels  entering  the  tumor,  and 
the  small  ones  are  torn  instead  of  being  cut  as  in 
amputation ;  2,  septicemia  does  not  occur,  for  no 
portion  of  the  tumor  is  left  to  slough. 

When  the  tumor  is  higher  up,  or  within  the 
cavity  of  the  uterus,  torsion  is  equally  appropriate, 
and  more  easily  executed  than  amputation  with  or 
without  ligation.  Of  course  if  the  mouth  of  the 
uterus  is  not  open  enough  to  permit  the  seizure  of 
the  polypus  at  a  point  high  enough  to  secure  a 
sufficiently  firm  hold  upon  it,  dilation  is  just  as 
necessary  as  in  the  other  operations.  The  amount 
of  dilation,  however,  will  not  need  to  be  so  great. 
In  performing  this  operation,  the  operator  must 
guide  the  forceps  with  his  fingers  to  the  part  of  the 
tumor  necessary  to  enable  him  to  fasten  the  instru- 
ment uj)on  or  near  the  central  part  of  the  polypus. 
In  two  instances  where  the  tumor  was  too  large  to 
be  firmly  held  by  any  forceps  at  my  command,  I 
introduced  the  hand  inside  the  uterus  and  detached 
the  tumors  by  rotating  them  with  the  hand,  after- 
wards making  traction  with  the  forceps.  I  brought 
them  into  the  vagina  and  delivered  them  with  the 
obstetrical  forceps.  One  of  these  weighed  forty- 
six  ounces. 

To  perform  torsion  for  the  removal  of  a  polypus, 
the  surgeon,  after  fixing  the  instrument  firmly  in 
the  desired  position,  should  be  careful  to  twist  it 
enough  to  be  sure  of  its  detachment  before  com- 
mencing traction.  Not  less  than  from  four  to  six 
complete  revolutions  should  be  effected.  This  pro- 
cedure will  prevent  the  danger  of  lacerating  the 
tissues  of  the  uterus. 

The  greatest  objection  urged  against  the  opera- 
tion of  torsion  is  the  likelihood  of  lacerating  the 
wall  of  the  uterus  at  the  point  of  attachment.  If 
we  will  call  to  mind  what  was  said  about  the  rela- 
tive thickness  of  the  muscular  strata  upon  each 
side  of  the  different  kinds  of  fibrous  tumors,  Ave'  will  at  once  perceive 


Chassaignac's  ]fecraseur. 


EEMOVAL  OF  POLYPOID  TUMORS. 


661 


the  groundlessness  of  this  objection.  In  the  pendulous  variety  the 
whole  wall  of  the  uterus  is  outside  the  point  of  attachment  and  is 
strong  enough  to  resist  the  very  few  fibres  that  are  carried  down  with 
it.     Indeed,  in  the  polypus  there  is  almost  no  substantial  attachment 


Fig.  291. 


Small  Vulsellnm  Forceps. 


except  that  formed  by  the  investing  mucous  membrane.  If,  therefore, 
the  torsion  is  performed  with  sufficient  thoroughness  before  traction 
is  begun,  laceration  of  more  than  the  superficial  tissues  surrounding 

Fig.  292. 


Medium-sized  Vulsellum  Forceps. 


the  neck  of  the  tumor  is  next  to  impossible,  and  consequently  the 
operation  is  perfectly  safe. 

Hemorrhage  is  not  so  likely  to   occur  after  torsion  as  when  the 
tumor  is  amputated  by  the  knife,  or  scissors,  or  even  by  the  ecraseur. 


Fig.  293. 


Large  Vulsellum  Forceps. 


The  danger  of  hemorrhage,  then,  is  an  objection  that  cannot  with  any 
show  of  reason  be  urged  against  torsion.  I  have  never  seen  hemor- 
rhage succeed  torsion.  The  contractions  of  the  uterus  which  take 
place  after  removing  the  polypous  growth  from  the  cavity  of  the 
uterus,  in  the  great  majority  of  cases,  is  as  effective  in  the  prevention 
of  hemorrhage  as  it  is  when  its  contents  are  expelled  at  the  time  of 
labor.     I  trust  that  it  is  not  necessary  to  dilate  further  upon  this  part 


662  SURGICAL,  TREATMENT. 

of  the  subject.  However,  let  me  remind  the  reader  that  as  hemor- 
rhage, although  improbable,  is  yet  possible,  we  should  be  prepared  for 
it.  After  what  has  been  said  under  palliative  treatment  about  the 
management  of  this  complication,  it  will  not  be  necessary  to  enlarge 
upon  that  point. 

After  an  operation  of  this  kind  the  only  treatment  necessary  is 
perfect  quiet  a  few  days,  cleanliness  by  injections,  and  if  needful 
the  administration  of  anodynes  to  quiet  pain.  When  a  tumor  has 
been  removed  from  high  up  in  the  uterus  the  patient  should  of  course 
be  carefully  watched,  and  if  symptoms  of  inflammation  or  septicaemia 
arise  they  should  be  treated  by  suitable  measures. 

Surgical  operations  having  the  relief  of  hemorrhage  for  their  primary 
object,  but  which  sometimes  eventuate  in  the  cure  of  the  tumor,  have 
been  recommended  and  successfully  practiced. 

The  first  I  shall  mention,  is  that  brought  into  general  notice  by  the 
late  J.  Baker  Brown,  viz.,  incising  the  cervix. 

Mr.  Brown  first  discovered  that  free  incision  of  the  cervix  would 
check  hemorrhage  by  doing  it  as  a  preliminary  step  to  coring  or 
gouging  out  some  of  the  tumor.  He  says,  in  tumors  of  recent  origin 
and  moderate  size,  free  incision  not  only  checks  the  hemorrhage,  but 
often  arrests  the  growth  of  the  tumor,  and  even  causes  its  disappear- 
ance. 

Of  fourteen  cases  thus  treated,  in  two  only  was  it  necessary  to  incise 
or  gouge  the  tumor. 

When  the  vagina  is  small  he  first  dilates  it  with  bougies  (some 
prefer  sponge  surrounded  by  thin  india-rubber  tubing).  After  the 
preparation  of  the  vagina  is  satisfactorily  accomplished,  he  exposes 
the  cervix  by  introducing  Sims's  speculum,  seizes,  fixes,  and  incises  it 
freely,  its  whole  length  from  within  outward,  with  Simpson's  metro- 
tome, the  incisions  being  made  on  both  sides.  He  then  plugs  the 
cavity  thus  made  with  lint  saturated  with  sweet-oil  (if  the  oil  was  car- 
bolized  it  would  be  better),  to  prevent  hemorrhage  and  to  exclude 
air.  Mr.  Brown  lays  great  stress  upon  a  thorough  plugging  of  the 
cervix  after  the  operation,  and  filling  the  vagina  with  cotton  to  sup- 
port the  cervical  plug.  He  allows  this  to  remain  for  forty-eight 
hours.  He  insists  upon  making  the  incision  in  the  cervix  to  extend 
within  the  internal  os  uteri.  The  cavity  produced  in  the  cervix  by 
the  incision  should  be  kept  dilated  until  the  surfaces  cicatrize.  If 
then  the  symptoms  are  not  relieved,  he  proceeds  to  the  operation  of 
gouging  out  a  piece  of  the  most  dependent  part  of  the  tumor.  This 
may  be  done  with  a  knife,  but  he  prefers  pointed  scissors. 

The  object  of  removing  a  part  of  the  tumor  is  to  inaugurate  a  de- 
structive inflammation,  which  will  result  in  the  disintegration  and 
expulsion  of  the  tumor. 

Sir  J.  Y.  Simpson  introduced  the  cautery  or  caustics  into  the  sub- 


ENUCLEATION.  663 

stance  of  the  tumor  for  the  same  purpose.  In  two  instances  I  have 
caused  fibrous  tumors  to  disappear  by  passing  cotton-wool  into  them. 
A  large  trocar  was  thrust  through  the  cervical  cavity  as  deep  into 
the  tumor  as  practicable,  and  after  the  stilet  was  withdrawn,  several 
pieces  of  cotton  secured  by  thread  around  them,  were  passed  to  the 
extremity  of  the  canula  into  the  tumor  and  held  there  by  a  probe, 
while  the  canula  was  also  withdrawn.  A  discharge  of  fetid  pus  and 
serum  followed  moderate  inflammation,  and  the  tumor  grew  smaller 
until  it  disappeared. 

With  my  present  experience,  I  would  commend  the  administration 
of  ergot,  as  soon  as  the  tumor  was  affected  by  either  of  these  opera- 
tions, with  a  view  to  aid  in  the  expulsion  of  the  growth. 

For  the  relief  of  excessive  hemorrhage,  Dr.  Atlee  passed  a  blunt- 
pointed  bistoury  into  the  cavity  of  the  uterus,  and  by  turning  the  edge 
of  the  instrument  upon  the  tumor,  cut  deeply  into  it.  The  dilatation 
of  the  cervix,  so  generally  indispensable,  can  be  done  by  compressed 
sponge  or  sea-tangle  tents,  instead  of  incision. 

Enucleation. 

This  term  is  applied  to  the  operation  of  splitting  the  capsule  and 
turning  the  tumor  out  of  its  bed. 

In  favorable  cases  this  operation  is  easily  performed,  but  such 
, cases  are  very  rare ;  generally  it  is  one  of  the  most  formidable  and 
dangerous  operations  that  we  are  called  upon  to  perform.  I  say  this, 
with  reference  to  the  operation,  when  it  is  done  by  the  most  skilful 
and  efficient  gynecologist.  In  the  hands  of  the  reckless,  uninstructed, 
and  inexperienced,  it  is  still  more  likely  to  be  done  badly,  and  indeed 
barbarously  than  any  other  operation. 

The  operation  of  enucleation  should  be  confined  to  submucous 
tumors,  or,  to  speak  more  definitely,  to  tumors  situated  between  the 
central  stratum  of  muscular  fibre  and  the  mucous  membrane.  The 
intrusion  of  such  tumors  into  the  cavity  of  the  uterus  enables  us  to 
attack  them  from  that  cavity,  and  the  thick,  strong  layer  of  muscular 
fibre  lying  outside  of  the  tumor,  makes  the  operation  less  dangerous 
by  protecting  the  peritoneal  cavity  from  the  violence  which  might 
otherwise  result  from  the  most  cautious  use  of  the  instruments. 

When  are  we  justified  in  making  an  attempt  at  enucleation? 

The  first  item  in  the  answer  to  this  question  is,  when  it  is  evident 
that  the  patient's  life  will  soon  be  sacrificed  if  the  tumor  is  not  in 
some  way  disposed  of.  The  second  item  is,  where  every  reasonable 
palliative  measure  has  been  tried  without  success,  or  where  there  is 
not  time  to  wait  for  their  trial,  if  such  a  condition  can  exist;  and  I 
may  add  a  third,  where  appropriate  attempts  have  been  made  and 
failed  to  break  them  up  and  expel  them  with  ergot.     Some  will  object. 


664  SUEGHCAL  TREATMENT. 

saying  that  ergot  will  not  do  this  with  any  uniformity ;  to  which  I 
would  answer,  that  I  do  not  believe  the  objectors  have  given  it  a 
thorough  and  intelligent  trial.  Some  will  further  object,  by  saying, 
that  the  septic  fever  attendant  upon  such  expulsion  is  more  dangerous 
than  the  operation  of  enucleation ;  to  which  I  would  answer,  that  my 
cases  will  not  bear  out  the  objection.  I  will  also  add,  that  the  general 
practitioner  will  conduct  a  case  of  expulsion  more  successfully  than 
he  can  the  operation  of  enucleation. 

The  first  step  in  enucleation  is  thorough  dilatation  of  the  cervix,  if 
it  is  not  already  sufficiently  open.  The  dilatation  should  be  sufficient 
to  permit  the  fingers  to  pass  as  far  up  into  the  cavity  of  the  uterus  by 
the  side  of  the  tumor  as  they  can  be  made  to  reach.  If  the  vagina  is 
small,  it  should  also  be  prepared  by  stretching  or  dilating  it. 

When  these  conditions  have  been  obtained,  the  patient  should  be 
placed  upon  her  left  side  with  her  left  hand  behind  her,  and  by  Sims's 
speculum,  the  cervix  and  tumor  exposed  to  view.  The  cervix  should 
then  be  seized  with  vulsellum  forceps,  drawn  down  as  much  as  possi- 
ble, and  held  firmly  by  an  assistant  until  the  operation  is  completed, 

Fig.  294. 


Sims's  Enueleator. 


varying  the  direction  of  the  traction  as  the  operator  may  require.  The 
capsule  may  then  be  opened  by  making  an  incision  with  long  curved 
scissors,  at  the  junction  of  the  tumor  with  the  wall  of  the  uterus  the 
whole  width  of  the  tumor ;  at  the  middle  of  the  incision  another  should 
be  commenced,  and  carried  as  high  up  over  the  longitudinal  centre  of 
the  tumor  as  possible. 

These  incisions  should  not  penetrate  the  tumor  to  any  great  depth. 
They  should  simply  divide  the  capsule,  and  when  the  capsule  is  not 
adherent,  the  space  between  it  and  the  tumor  will  be  easily  recognized. 
The  fingers  can  then  be  inserted  between  the  capsule  and  the  tumor, 
thus  separating  them  as  high  as  the  operator  can  reach.  This  separa- 
tion should  extend  around  the  whole  circumference  of  the  growth. 

The  fingers  will  not  be  long  enough,  usually,  to  reach  over  the  upper 
end  of  the  tumor ;  the  separation  may  be  completed  by  Sims's  enuele- 
ator as  seen  in  Fig.  294.  It  may  be  passed  with  the  concave  side  next 
to  the  tumor,  gently  to  the  top,  and  then  passed  around  in  any  direc- 
tion until  the  separation  is  complete. 

While  this  last  part  of  the  operation  is  being  accomplished,  another 
vulsellum  should  be  fastened  upon  the  tumor  as  high  up  as  possible, 


ENUCLEATION.  665 

sixid  by  traction  made  to  depress  and  steady  it.  When  the  tumor  is 
thus  separated  from  its  capsule,  we  should  make  an  effort  to  turn  it 
upon  its  longitudinal  axis. 

This  will  enable  us  to  determine  whether  it  is  entirely  detached  or 
not,  as  well  as  to  dislodge  it  from  the  muscular  bed  into  which  it  has 
been  moulded.  If  the  detachment  is  not  complete,  the  point  of  resist- 
ance will  generally  be  discoverable  by  swaying  it  from  one  side  to  the 
other,  or  backward  and  forward,  thus  enabling  us  to  apply  the  enucle- 
ator  to  the  right  place,  and  complete  the  separation.  At  this  stage  of 
the  operation  we  may  make  more  traction ;  the  dislodgment  will  be 
facilitated  by  pressure  upon  the  fundus  of  the  uterus  by  the  hand  of 
an  assistant.  When  the  tumor  is  not  too  large,  it  will  descend  as  we 
pull  upon  it,  and  pass  out  through  the  vagina.  If,  however,  it  is  so 
large  that  it  cannot  be  made  to  pass  through  the  vagina  in  this  way, 
then  the  tumor  should  be  split  by  the  scissors  from  the  bottom  up- 
ward, as  near  the  top  as  possible,  without  danger  of  wounding  the  fun- 


FiG.  295. 


Sims's  Guarded  Hook  to  aid  in  drawing  the  Tumor. 

dus  of  the  uterus,  and  then  (as  Dr.  Sims  instructs  us)  one-half  should 
be  seized  by  the  vulsellum  and  drawn  down,  so  as  to  cause  the  tumor 
to  undergo  evolution ;  the  portion  grasped  coming  down  first,  and  by 
virtue  of  its  attachment  at  the  top,  brings  the  other  after  it ;  but  if  this 
cannot  be  done,  we  must  cut  off  the  part  in  the  grasp  of  the  vulsellum, 
seize  another  portion  and  treat  it  in  the  same  manner,  until  the  whole 
is  removed  by  pieces. 

Under  favorable  circumstances  this  operation  may  be  performed  as 
above  described ;  but  obstacles  will  sometimes  be  met  with  that  will 
give  the  best  operators  much  trouble,  and  render  the  results  very 
unsatisfactory. 

The  first  I  will  mention  is  that  presented  by  imperfect  capsulation, 
or  adhesion  of  the  tumor  to  the  walls  of  the  uterus.  Some  cases  occur 
where  the  tumor  is  not  isolated  by  a  capsule  from  the  uterine  struc- 
tures, but  the  substance  seems  to  be  continuous  with  them. 

Whether  this  condition  depends  upon  original  formation,  or  is  the 
result  of  disease,  which  causes  adhesion  between  the  surfaces  of  the 
tumor  and  the  capsule,  I  am  not  able  to  say ;  but  in  either  case  it 
presents  an  insurmountable  obstacle  to  the  perfect  removal  of  the 
tumor  ;  and,  if  this  condition  could  be  diagnosed  beforehand,  it  would 
contraindicate  the  operation  for  enucleation. 

When  in  the  performance  of  the  operation  we  meet  with  this  ob- 


666  SURGICAL  TEEATMENT. 

stacle,  and  can  clearly  ascertain  its  existence,  I  think  it  would  be  best 
to  gouge  out  as  much  of  the  tumor  as  we  could  safely  remove,  and 
then  commence  the  administration  of  ergot,  to  remove  the  remainder. 
I  would  do  this,  because  cutting  through  the  superficial  layer  of  the 
tumor  would  be  sure  to  disturb  its  vitality. 

The  next  obstacle  to  the  removal  of  the  tumor  by  enucleation  is 
the  great  size  to  which  it  may  attain.  I  have  already  spoken  of  the 
necessity  of  sometimes  cutting  the  tumor  in  pieces  with  scissors  to 
facilitate  its  removal.  The  wire  ecraseur  will  often  be  very  useful  in 
lessening  the  size  of  the  tumor. 

We  slip  the  wire  over  a  portion  of  the  tumor  and  cut  it  off,  then 
pull  down  more  with  the  vulsellum,  when  that  is  possible,  and  pass 
the  wire  over  another  piece,  and  so  on  until  it  is  small  enough  to 
remove. 

This  plan,  where  practicable,  and  especially  in  the  hands  of  the 
experienced  oiDcrator,  is  the  safest  way.  Dr.  Thomas's  serrated  spoon, 
or  a  very  small,  crescent-shaped  knife,  such  as  is  used  by  Dr.  E. 
Warren  Sawyer,  of  this  city,  may,  by  careful  use,  aid  us  in  this 
respect. 

Hemorrhage  constitutes  a  very  formidable  complication,  in  rare 
instances,  in  the  operation  of  enucleation.     I  have  never  met  with 

Fig.  296. 


Thomas's  Serrated  Spoon. 


this  difficulty  in  the  removal  of  these  tumors  by  any  method ;  but 
there  are  too  many  cases  on  record  to  leave  any  doubt  that  we  should 
be  provided  with  the  means  of  meeting  hemorrhage  of  the  most  for- 
midable degree. 

In  considering  this  matter  in  relation  to  the  cases  reported,  I  believe 
it  to  be  the  result  of  inertia,  or  want  of  firm  contraction  in  the  mus- 
cular fibre,  or  on  account  of  the  separation  of  a  vessel  in  the  uterine 
walls.  In  either  case,  if  we  continue  the  operation,  we  should  follow 
the  examjDle  of  Dr.  Emmet  in  throwing  ice-water  freely  into  the 
cavity  of  the  uterus.  I  would  also  resort  to  obstetric  doses  of  ergot ; 
both  of  them  would  serve  to  contract  the  vessels  of  the  uterus,  and 
overcome  the  inertia  by  prompting  the  uterine  fibres  to  act.  If,  in 
spite  of  these  remedies,  the  hemorrhage  is  so  copious  as  to  make 
delay  very  dangerous^  we  may  inject  the  uterus  with  tincture  of  iodine; 
but  I  should  greatly  prefer  immediate  and  complete  plugging  to  any- 
thing else.  If  the  hemorrhage  has  been  sudden,  shall  we  proceed 
with  the  operation  ?  I  think  not,  but  would  assign  this  to  the  cate- 
gory of  cases  which  should  be  treated  by  ergot. 


LAPAROTOMY.  667 

What  has  been  said  of  enucleation  has  reference  more  particularly 
to  deeply-seated  submucous  tumors  which  project  into  the  cavity,  but 
are  imbedded  their  whole  length  in  the  wall  of  the  uterus.  The  more 
superficial  or  sessile  variety  of  submucous  tumors  project  so  far  into 
the  cavity  as  to  appear  to  be  implanted  upon  the  wall  beneath  the 
mucous  membrane  of  the  uterus.  The  attachment,  or  base,  upon 
which  it  i?its,  is  nearly  or  quite  the  size  of  the  tumor.  This  variety 
can  be  removed  with  much  more  facility. 

After  exposing  the  tumor,  and  steadying  it  by  traction  with  the  vul- 
sellum,  it  may  be  separated  from  the  wall,  and  that  very  neatly  by  the 
serrated  spoon.  This  instrument  should  be  inserted  through  the  cap- 
sule, at  the  juncture  between  the  tumor  and  the  uterus,  by  a  rotary 
sawing  motion ;  the  growth  severed  by  passing  it  through  the  capsule 
in  any  direction  where  the  attachment  exists. 

This  is  Dr.  Thomas's  method  of  removing  this  variety  of  tumors. 

Dr.  Emmet  pulls  them  steadily  and  persistently  down  into  or  toward 
the  vagina ;  this  allows  the  upper  portion  of  the  uterus,  from  which 
the  tumor  is  withdrawn,  to  contract.  Further  traction  upon  the  tumor 
gives  room  for  the  fibres  beneath  the  point  of  implication  also  to  con- 
tract, until  the  circumference  of  the  attachment,  becoming  smaller, 
assumes  a  pedunculated  form,  and  may  be  severed  by  the  ecraseur, 
scissors,  or  knife.  This  form  of  tumor  may  also  be  removed  by  pass- 
ing an  ecraseur  over  and  amputating  a  part  of  it,  and  then,  by  means 
of  the  finger  or  enucleator,  remove  the  remainder. 

Patients  who  have  undergone  any  of  these  operations  for  removal 
of  fibrous  tumors  may  die  from  shock,  hemorrhage,  inflammation,  or 
septicsemia. 

For  the  treatment  of  shock,  I  will  refer  the  reader  to  the  subject  as 
taught  in  the  after-treatment  of  ovariotomy. 

I  have  already  said  sufficient  upon  the  subject  of  treatment  of 
hemorrhage  as  a  complication  in  such  cases. 

Inflammation,  when  it  occurs,  should  be  treated  as  in  the  after-treat- 
ment of  ovariotomy. 

Septicsemia  may  be  more  effectually  treated  in  connection  with  this 
than  almost  an}^  other  of  the  great  operations,  as  we  can  keep  the 
cavity  clean  by  hot-water  injections,  and  disinfected  by  carbolic  acid. 
For  the  general  treatment,  I  will  refer  the  reader  to  the  after-treatment 
of  ovariotomy. 

Laparotomy 

For  the  extirpation  of  the  tumor,  is  another  surgical  resource,  of 
which  we  may  avail  ourselves  under  circumstances  where  the  employ- 
ment of  less  hazardous  measures  is  either  impracticable  or  unavail- 
ing. 

The  extirpation  of  the  tumor,  where  it  is  subserous  and  pediculated, 


668  SURGICAL   TREATMENT. 

has  been  performed  a  large  number  of  times  successfully ;  and  where 
the  tumor  is  not  adherent,  there  is  no  great  difficulty  in  removing  it  in 
this  way. 

The  incision  through  the  abdominal  wall  maybe  made  in  the  same 
place  and  in  the  same  way  as  for  ovariotomy,  although  it  will  be 
evidently  necessary  to  make  it  larger. 

The  pedicle  being  exposed  and  ligated  by  a  double  silk  ligature,  it 
will  be  found  that  the  substance  through  and  around  which  the  liga- 
ture is  jDassed  is  not  so  firm  as  the  pedicle  of  an  ovarian  tumor ;  hence 
it  will  be  necessary  to  be  more  careful,  lest  it  give  way  and  cause  sec- 
ondary hemorrhage. 

The  ligature  should  not  be  passed  through  any  part  of  the  tumor, 
but  between  it  and  the  uterine  substance ;  then,  to  get  sufficient  sub- 
stance beyond  the  ligature,  the  capsule  may  be  divided  an  inch  from 
the  ligature  and  the  tumor  enucleated. 

When  the  tumor  is  sessile,  instead  of  being  pediculated,  and  the 
base  too  broad  to  be  included  in  a  ligature  or  clamp  after  the  abdomen 
has  been  ojDened,  it  may  be  enucleated  by  splitting  the  capsule  and 
peeling  it  out  with  the  fingers.  I  would  suggest  that  when  enucleation 
has  been  thus  performed,  an  opening  be  made  from  the  bed  of  the 
tumor  into  the  uterus,  so  that  the  discharge  from  the  empty  capsule 
may  find  its  way  out  through  the  uterus  and  vagina. 

To  secure  this  evacuation,  we  might  pass  a  drainage  tube  through 
the  opening  into  the  vagina.  "VVTiere  this  or  some  other  effective  ar- 
rangement for  drainage  is  made,  the  capsule  may  be  closed  by  silk 
sutures,  and  the  abdominal  wound  treated  as  for  ovariotomy.  If  the 
capsule  should  not  be  large,  and  the  operation  has  been  performed,  as 
it  always  should  be  performed,  under  the  antiseptic  conditions,  it  may 
not  be  necessary  to  make  any  provisions  for  drainage. 

When  a  subserous  tumor  is  situated  on  the  posterior  wall,  occupy- 
ing the  cul-de-sac  behind  the  uterus,  it  may  be  removed  by  making  an 
incision  along  the  median  line  of  the  posterior  vaginal  wall  and  re- 
moving the  tumor  through  the  vagina.  Dr.  R.  S.  Sutton,  of  Pittsburg, 
has  successfully  removed  one  in  this  way,  as  also  has  Dr.  Clifton  Wing, 
of  Boston. 

Of  course  none  but  the  small-sized  tumors  can  be  removed  by  this 
method. 

The  thermo-cautery,  or  the  actual  cautery,  should  always  be  in 
readiness  to  stop  hemorrhage  in  either  of  these  operations. 

Laparo-hysteredomy. 

The  last  measure  I  will  mention,  as  one  resorted  to  for  the  relief  of 
patients  afflicted  with  these  tumors,  is  laparo-hysterectomy,  or  the  re- 
moval, partially  or  wholly,  of  the  uterus  with  the  tumor. 

This   operation   resembles  in  many  respects  that  of  ovariotomy. 


LAPARO-HYSTERECTOMY.  669 

Our  preparation  of  the  j)atient  should  be  the  same.  The  anaesthetic 
and  the  carbolic  spray  are  used  in  the  same  way,  as  also  in  the  anti- 
septic dressing. 

When  we  undertake  the  operation,  we  should  be  especially  well 
prepared  with  means  of  arresting  hemorrhage.  To  this  end  we  should 
have  in  readiness  the  therm o-cautery,  a  number  of  hsemostatic  forceps, 
persulphate  of  iron,  etc.,  and  every  other  arrangement  should  be  com- 
plete, so  that  there  might  be  no  delay,  as  the  operation  is  almost  of 
necessity  one  of  long  duration  under  the  most  favorable  circumstances ; 
and  it  should  be  remembered  that  everything,  which  may  shorten  the 
duration  of  the  operation  is  of  great  importance,  as  the  longer  it  lasts, 
the  more  depressing  its  effects.  For  fear  that  what  I  may  say  should 
encourage  precipitation,  I  would  protest  against  hurry,  and  advise  de- 
liberation in  all  the  steps  of  the  operation. 

The  incision  is  made  in  the  same  place  and  manner  as  in  ovari- 
otomy ;  first  a  small  incision,  say  four  inches  long,  for  exploration,  to 
ascertain  the  character  of  the  tumor,  its  probable  adhesions,  and  its 
relation  to  the  viscera.  As  some  viscera,  especially  the  intestine,  is 
more  frequently  found  to  lie  across  the  front  part  of  the  tumor,  the 
necessity  of  ascertaining  any  such  condition  is  much  greater  than  in 
ovariotomy. 

When  it  comes  to  the  separation  of  the  adhesions  and  the  removal 
of  the  tumor,  the  size  of  the  incision  must  be  increased  sufficiently  to 
'permit  the  extraction  of  the  whole  mass,  instead  of  an  effort  being 
made  to  lessen  the  size  of  the  tumor,  as  in  ovariotomy. 

An  exception  may  be  made  to  this  teaching,  if  the  tumor  is  not  en- 
tirely solid,  but  of  the  fibro-cystic  variety.  In  this  case,  if  a  large  cyst 
presents  itself,  we  may  hold  the  tumor  close  to  the  incision  with  vul- 
sellum  forceps  and  evacuate  the  fluid  through  a  large  trocar,  or  an 
incision  into  the  wall  of  the  cyst.  If  in  doing  this  we  find  there  are 
a  number  of  cysts,  we  may  introduce  a  finger,  or  even  the  whole  hand, 
as  I  once  did,  into  the  centre  of  the  tumor,  and  break  it  up  as  far  as 
possible.  In  this  way  we  may  sometimes  very  greatly  lessen  the  size 
of  the  tumor. 

In  this  operation,  as  in  ovariotomy,  the  size  of  the  incision  is  of 
great  importance ;  in  no  case  should  we  risk  bruising  or  tearing  the 
abdominal  walls. 

In  operating  for  fibrous  tumors,  we  should  not  trust  to  the  sound 
in  searching  for  adhesions ;  the  hand  alone  should  be  used,  and  the 
whole  surface  examined  before  any  attempt  is  made  to  dislodge  the 
tumor. 

We  should  also  remember  that  the  adhesions,  as  a  rule,  are  more 
vascular  than  in  ovarian  tumor,  and  hence,  when  necessary,  they 
should  be  ligated  twice  and  cut  between  the  ligatures. 

When  solid,  the  tumor  may  be  lifted  from  its  bed  more  easily  by 


670  SURGICAL   TREATMENT. 

means  of  the  vulsellum  forceps  than  by  the  hands.  After  it  is  lifted 
out,  the  uterus  will  generally  be  found  to  be  removed  from  the  pelvis 
with  the  tumor  constituting  a  part  of  the  mass. 

If  there  are  no  more  adhesions  the  junction  between  the  tumor  and 
uterus  should  be  sought  for.  Sometimes  the  tumor  is  situated  so  low 
in  the  uterine  walls  that  the  appendages  are  carried  high  up,  and 
may  be  considerably  enlarged.  It  is  then  advisable  to  ligate  the 
ovarian  vessels  laterally  in  the  broad  ligament,  and  the  appendages 
near  the  uterus,  and  cut  between  the  fimbriated  extremity  of  the  tube 
and  the  lateral  ligatures.  The  peritoneal  edges  of  the  severed  broad 
ligament  may  then  be  united.  If  the  pedicle  be  thick,  and  the  uterine 
vessels  large,  we  may  place  a  rubber  tube  tightly  about  the  cervix,  and 
tie  the  vessels  above  the  tubing  before  the  tumor  is  cut  off.  The 
bladder  is  usually  in  close  proximity  and  must  be  carefully  avoided. 

There  are  two  methods  of  treating  the  pedicle,  the  extra-perito- 
neal and  the  intra-peritoneal.  When  treated  extra-peritoneally  the 
cervix  or  the  uterine  stump  must  either  be  inclosed  in  a  clamp,  con- 
stricted by  rubber  tubing,  or  ligated  with  heavy  silk,  before  being  cut 
off  above.  Spencer  Wells  was  the  first  to  treat  the  stump  extra-peri- 
toneally. He  transfixed  it  with  two  needles,  ligated  about  them  with 
a  figure-of-eight  ligature,  and  fastened  it  in  the  lower  end  of  the  wound. 
Pean  deserves  the  credit  of  having  developed  this  method.  He  passed 
two  needles  at  right  angles  through  the  stump,  and  ligated  it  in  halves 
under  them  by  wires.  If  bleeding  occurred  afterward,  the  wires  were 
tightened. 

On  account  of  the  liability  of  the  wire  to  cut,  and  the  ovarian 
vessels  to  slip  out  of  the  loop,  Hegar*  places  a  strong  elastic  ligature 
(rubber  tubing)  around  the  stump,  cuts  the  tumor  off,  sews  the  peri- 
toneal edges  of  the  abdominal  walls  to  the  peritoneal  covering  of  the 
stump  below  the  elastic  ligature,  and  transfixes  the  stump  with  two 
needles  to  hold  it  in  place. 

The  elder  Keith,  who  has  obtained  the  best  results  (35  recoveries 
out  of  38  cases),  fixes  the  pedicle  in  the  abdominal  wound  with  a 
clamp  or  wires. 

The  after-treatment  of  the  pedicle  treated  extra-peritoneally  is  usu- 
ally tedious,  for  the  portion  above,  and  sometimes  that  a  little  below, 
the  clamps  or  elastic  ligature  sloughs  out  and  leaves  a  large  deep 
ulcer  to  be  filled  with  granulations.  The  remaining  stump  under- 
goes considerable  retraction,  and  draws  the  abdominal  walls  down 
toward  the  pelvic  cavity. 

Schroeder,t  who  was  the  chief  representative  of  the  intra-peritoneal 
method,  placed  a  rubber  ligature  around  the  uterus  and  appendages 

*  Operative  Gynakologie.     Hegar  and  Kaltenbach. 
t  Op.  cit. 


LAPAEO-HYSTERECTOMY.  671 

below  the  tumor,  and  cut  the  latter  off  at  its  junction  with  the  uterus 
as  a  piece  is  cut  out  of  a  melon  (wedge-shaped).  He  then  trimmed 
the  stump,  if  necessary,  till  the  peritoneal  edges  could  be  made  to 
cover  it,  and  disinfected  the  exposed  cervical  or  uterine  cavity  with  a 
ten  per  cent,  solution  of  carbolic  acid  or  the  thermo-cautery.  Having 
done  this  he  sewed  up  the  uterine  cavity,  and  then  the  raw  surfaces 
of  the  stump,  with  several  rows  of  stitches,  beginning  at  the  bottom 
and  culminating  at  the  top  with  a  fine  row  uniting  the  peritoneal 
edges.  He  used  catgut  for  the  uterine  cavity  and  peritoneal  edges, 
and  silk  for  the  rows  of  stitches  uniting  the  raw  surfaces  where  there 
was  apt  to  be  considerable  strain  ujDon  them. 

Dr.  Charles  T.  Parkes,  of  this  city,  ligates  the  stump  with  silk, 
thoroughly  sears  it  with  the  thermo-cautery  and  drops  it.  He  reports 
six  cases :  with  two  recoveries  treated  in  this  way,  and  four  deaths 
with  the  stump  treated  extra-peritoneally. 

Among  135  cases  Schroeder  lost  thirty  per  cent.  This  percentage 
in  the  cases  of  so  skilful  an  operator  would  indicate  that  the  dangers 
of  his  method  are  great,  or  that  it  was  but  imperfectly  developed. 
The  statistics  of  the  recorded  extra-peritoneal  operations  are  far  better, 
although  the  recovery  is  usually  more  tedious.  There  is  much  reason 
to  believe  that  Parkes's  method  approaches  more  nearly  to  the  ideal 
than  any  of  the  others. 

Woelfler  and  Hacker*  stitch  the  stumjD  (united  according  to  Schroe- 
der's  precepts)  into  the  wound,  so  that  it  is  extra-peritoneal  but  under 
the  abdominal  parietes. 

The  dif&culties  in  the  intra-peritoneal  method  are,  that  if  the  stump 
is  not  tied  tight  enough  hemorrhage  will  result,  if  tied  too  tight  or  too 
extensively  sloughing  may  occur. 

"  Dr.  Leon  Labb^  communicated,  at  a  late  meeting  of  the  Academie  de  Medicine,  a 
note  relative  to  a  modification  of  the  operation  of  hysterectomy  as  applied  to  fibrous 
tumors  (exsanguinification  of  the  tumor). 

"  Gastrotomy  applied  to  the  treatment  of  fibrous  tumors  of  the  uterus  is  an  opera- 
tion about  which  there  is  no  longer  any  dispute.  The  note  which  M.  Labbe  com- 
municated to  the  Academy  is  not  for  the  purpose  of  describing  this  operation,  but 
simply  to  make  known  an  important  modification  that  he  has  introduced  in  the  opera- 
tive process. 

"The  quantity  of  blood  contained  in  these  enormous  uterine  tumors  is  always  con- 
siderable; it  is  certain  that  the  loss  of  this  blood  by  the  ablation  of  the  tumor  is  a 
factor,  the  importance  of  which  cannot  be  passed  over,  especially  if  we  consider  that 
the  extirpation  of  these  tumors  almost  always  takes  place  in  the  cases  of  women  who 
are  in  an  advanced  state  of  cachexia.  Based  upon  the  principle  which  had  led  Es- 
march  to  apply  a  compress  bandage  on  limbs  which  were  to  be  amputated,  M.  Labb^ 
thought  the  same  bandage  could  be  utilized  to  press  back  into  the  general  circulation 
the  blood  contained  in  large  uterine  tumors,  and  thus  practice  a  kind  of  transfusion. 

"The  patient  for  whom  he  had  occasion  to  apply  this  principle  for  the  first  time, 

*  Schroeder,  op.  cit. 


672  SURGICAL   TREATMENT. 

was  in  a  deplorable  condition  before  the  operation,  and  succumbed  six  days  later  to 
septicemia ;  but  M.  Labb^  has  been  able  to  prove  that  the  enormous  fibroma  upon 
which  compression  was  first  practiced  was  entirely  exsanguined,  and  that  about  a  litre 
of  blood  was  by  this  means  restored  to  his  patient. 

"  The  theory  which  led  M.  Labb^  to  apply  Esmarch's  compress  to  restore  to  the 
general  circulation,  at  the  time  of  their  extirpation,  the  blood  contained  in  such  great 
abundance  in  the  fibro-myomas  of  the  uterus,  is  very  clearly  justified  by  the  case  which 
has  been  reported  to  the  Academy. 

"  The  peculiar  conformation  of  the  tumor  was  such  that  no  very  particular  method 
was  employed  in  this  case ;  but  if  the  tumor  to  be  operated  on  is  more  regular  in  form 
we  would  have  just  reason  to  fear  that  the  application  of  the  elastic  band  might  present 
some  difBcuIties.  In  this  case,  to  fasten  the  band  and  give  it  a  support  we  should 
transfix  the  tumor  near  its  summit  by  one  or  more  metallic  needles.  Several  of  these 
needles  may  even  be  placed  at  different  heights  so  as  to  give  support  to  the  compress, 
and  to  prevent  its  slipping. 

"M.  Labb6  concludes : 

"1st.  That  there  must  be  a  positive  advantage,  in  operations  on  large  uterine  fibro- 
myomas  removed  by  gastrotomy,  in  restoring  to  the  patient  the  blood  which  these 
tumors  always  contain  in  large  quantity. 

"  2d.  That  this  result  may  be  employed  in  a  complete  manner  by  applying  to  the 
tumor  Esmarch's  compress,  or  any  other  compress  endowed  with  the  same  elastic 
properties."— G'aze^ie  Hebdoraadaire,  6  Aout,  1880  ;  American  Journal  Medical  Sciences, 
October,  1880. 

When  the  hgature  is  satisfactoril}^  applied  we  must  remember  also 
that  in  cutting  away  the  tumor  there  is  great  danger  of  retraction  of 
the  parts  included  in  it.  The  abdomen  must  be  carefully  cleansed 
and  hemorrhage  entirely  checked  before  closing  the  wound. 

The  after-treatment  of  these  cases  is  more  difficult  than  in  ovari- 
otomy, as  the  shock  is  ordinarily  much  greater,  and  inflammation  and 
septicaemia  more  likely  to  follow  the  operation. 

I  do  not  believe  the  complete  extirpation  of  the  uterus  and  ovaries 
^  will  bear  any  reasonable  comparison  with  ovariotomy,  even  double 
ovariotomy. 

In  comparing  these  operations  we  must  remember  that  when  the 
uterus  and  both  ovaries  are  removed,  the  whole  genital  system,  with 
all  the  reflex  capacities  and  sympathetic  relations,  is  suddenly  torn 
from  its  connections.  The  centric  connections  supplied  to  these  organs 
by  a  complete  system  of  nerves ;  the  moral,  emotional,  and  physical 
energies  they  are  continually  exerting  over  the  whole  of  the  rest  of 
the  organism  are  destroyed.  The  importance  of  the  relations  between 
the  genital  system  of  woman  and  the  rest  of  her  body  and  brain  is  so 
great  that  it  can  scarcely  be  appreciated.  These  relations  constitute 
the  major  part  of  her  life. 

From  such  considerations,  I  can  but  believe  that  the  shock  of  this 
operation  is  incomparably  greater  than  in  ovariotomy  or  double 
oophorectomy. 

When  one  ovary  is  removed,  the  other  maintains  the  ovarian  in- 


OOPHORECTOMY^  673 

fluence  over  the  uterus  and  the  system  at  large.  When  both  are  re- 
moved, there  is  still  left  the  larger  part  of  the  genital  nervous  system, 
with  its  relations,  although  impaired,  not  entirely  severed ;  and  we 
know,  from  observation,  that  in  such  cases  womanhood  is  well  pre- 
served. 

In  operations  of  this  kind,  conservative  surgery  is  of  the  greatest 
im]3ortance,  and  we  ought  never  to  remove  the  ovaries  when  we  can 
preserve  them. 

While  there  will  continually  occur  cases  for  which  this  operation  is 
the  only  remedy,  experience  will  prove  it  to  be  an  operation  of  much 
more  gravity  than  ovariotomy  in  any  of  its  forms. 

Kimball,  Burnham,  H.  R.  Storer,  Thomas,  and  other  Americans 
have  performed  this  operation  successfully. 

In  Europe,  Pean,  Koeberle,  Wells,  Clay,  Schroeder,  and  others  have 
contributed  toward  perfecting  hysterectomy  for  fibrous  tumors. 

Oophorectomy — Battey''s  Operation — Spaying. 

These  are  terms  intended  to  designate  an  operation  for  the  removal 
of  the  ovaries. 

To  Dr.  Robert  Battey,  of  Rome,  Georgia,  is  due  the  credit  of  first 
removing  the  ovaries  for  the  purpose  of  artificially  inducing  the 
menopause. 

-  The  knowledge  that  the  change  of  life  generally  brings  relief  from 
the  intolerable  and  irremediable  forms  of  oophoro-neuroses  that  so 
often  perplex  the  practitioner,  would  lead  to  the  hope  that  the  re- 
moval of  these  bodies  would  produce  similar  cures.  This  operation 
has  been  before  the  professional  public  for  about  eleven  years,  and  the 
mortalit}^  which  was  at  first  above  twenty  per  cent,  has  now  fallen 
below  ten  per  cent.  Dr.  Paul  F.  Munde  {American  Journal  of  Obstetrics) 
very  correctly  observes  that  if  the  positive  benefits  of  the  operation 
were  as  assured  as  the  favorable  rate  of  mortality,  the  opj>osition  to 
it  would  soon  cease.  The  operation  has  also  been  repeatedly  per- 
formed for  the  purpose  of  arresting  the  growth  of  fibrous  tumors  of 
the  uterus,  on  account  of  the  favorable  effect  the  natural  menopause 
so  generally  produces  upon  them,  and  in  some  instances  with  very 
favorable  results. 

We  should  not  forget,  however,  that  menopause  is  not  the  change 
of  life. 

This  condition — menopause — is  sometimes  brought  about  by  some 
of  the  very  conditions  for  which  Battey 's  operation  is  performed  with- 
out producing  change  of  life. 

It  is  true  that  the  ovary,  if  not  the  essential  agent,  is  certainly 
necessary  to  the  proper  development  of  the  female  genital  organs. 
After  the  genital  apparatus  is  mature,  it  is  probably  the  fountain  of 

43 


674  SURGICAL    TREATMENT. 

the  excito-motor  influence  upon  which  depend  the  functions  of  the 
uterus  and  its  appendages  in  all  their  relations  to  the  generative  acts. 
The  ovaries  ought  not,  therefore,  to  be  classed  as  appendages  to  the 
uterus ;  rather  the  latter  is,  in  the  proper  sense,  an  appendage  to  the 
former. 

As  an  accompaniment  of  ovulation,  which  is  the  development  and 
disengagement  of  the  ovule,  the  trophic  energies  of  the  uterus  are  ex- 
cited in  corresponding  degree. 

The  repletion  and  activity  of  its  circulator}^  system  corresponds  to 
like  changes  transj)iring  in  the  ovaries,  and  the  nervous  system  of  the 
uterus  is  acted  upon  by  that  of  the  ovaries,  prompting  glandular 
changes  in  the  mucous  membrane. 

Even  the  intramenstrual  growth  and  hypertrophy  of  fibrous  and 
other  tissues  of  the  uterus  are  but  the  reflex  complement  of  the  stromal 
h3'pertrophy  of  the  ovaries.  As  the  ovarian  excito-motor  stimulation 
is  withdrawn  from  the  uterus,  involution  simultaneously  occurs  in  the 
two.  It  is  true  that  the  removal  of  the  ovaries  withdraws  the  source 
of  the  excito-motor  influence  from  the  uterus,  and  this  generally 
brings  about  the  menopause  in  the  sense  of  the  cessation  of  periodical 
hemorrhages;  but  the  same  operation,  after  the  uterus  has  obtained 
maturity  of  organization,  and  especially  when  its  tissues  have  become 
hypertrophied  (vascular,  nervous,  and  muscular),  leaves  a  large,  highly 
organized  organ  without  its  regulating  apparatus,  the  subject  of  any 
morbific  cause  which  in  its  nature  has  any  aptitude  for  the  production 
of  uterine  derangement. 

We  see  this  illustrated  in  the  case  given  by  Dr.  Trenholme,  the 
history  of  which,  subsequent  to  the  operation,  I  give  below. 

This,  I  think,  is  the  effect  produced  by  suddenly  removing  the  ova- 
ries in  large  fibrous  tumors  of  the  uterus.  In  smaller  growths,  and  a 
less  vascular  state  of  the  uterus,  the  same  conditions  exist,  and  the 
same  consequences  will  follow,  only  in  a  less  noticeable  degree. 

The  senile  menopause,  one  of  the  symptoms  of  the  change  of  life,  is 
the  consequence  of  gradual  changes  in  all  of  the  organs  concerned. 
This  change  is  a  degeneration  of  the  genital  organs. 

The  tissues  are  not  merely  diminished  in  size,  but  they  degenerate 
into  those  of  a  lower  order  of  organization,  and  this  same  degeneration 
extends  itself  to  the  morbid  growths  of  the  organs. 

Tumors  lose  their  vascularity,  their  fibres  disappear,  and  the  whole 
becomes  a  degenerate  mass. 

It  is  not  certain  how  much  of  this  general  and  regular  degeneration 
is  due  to  the  presence  of  the  ovaries  and  their  excito-motor  energies  in 
prompting  it  and  in  governing  its  nature. 

It  is  a  plausible  supposition,  however,  that  as  the  ovarian  changes 
and  influences  are  so  great  in  building  up  the  uterus  and  sustaining 


OOPHORECTOMY.  675 

its  functions,  it  might  be  as  efficient  in  its  retrograde  transformation, 
thus  maldng  it  more  complete. 

The  removal  of  the  ovaries  in  the  presence  of  a  large  fibroid  and 
hypertrophied  uterus,  simply  takes  away  their  governing  agency 
before  the  process  of  degeneration  has  begun.  We  have  then  a  highly- 
organized  uterus  and  tumor,  and  if  degeneration  takes  place  at  all, — 
which  I  very  much  doubt, — it  is  not  normal  in  any  respect,  and  may 
be  the  cause  of  morbid  instead  of  salutary  conditions. 

AVe  then  exchange  one  evil  for  another ;  a  greater  for  a  lesser  it  may 
be;  to  the  advantage  of  the  patient  somewhat,  but  yet  not  so  as  to 
make  a  perfect  cure. 

Dr.  E.  H.  Trenholme,  of  Montreal,  reports  a  case*  of  abdominal 
oophorectomy  for  a  large  fibrous  growth  of  the  uterus  in  January, 
1876.  Severe  uterine  pains  and  hemorrhage  were  the  actuating  reasons 
for  the  operation.  The  patient,  according  to  her  own  account,  was 
very  much  improved  for  four  months  succeeding  the  operation,  the 
uterus  then  (in  May,  1876)  suddenly  commenced  enlarging  and  gave 
her  very  great  pain.  The  enlargement  and  pain  were  accompanied 
by  copious  hemorrhage.  As  the  result  of  this  attack,  she  was  confined 
to  her  bed  more  or  less  constantly  for  three  months.  Recovering  from 
this  attack  she  was  able  to  support  herself  a  part  of  the  time  as  a  sales- 
woman, and  a  part  of  the  time  as  a  nurse,  for  several  months. 

In  December,  1877,  she  had  a  similar  attack  and  of  like  duration. 
The  patient  has  now  been  in  this  city  about  two  years,  and  I  have 
had  the  opportunity  of  seeing  her  in  two  or  three  of  these  attacks. 
The  pain  is  exceedingly  severe  and  requires  the  use  of  anodynes  in 
considerable  doses  to  relieve  it.  In  April,  1878,  one  of  these  attacks 
commenced  and  kept  her  in  bed  for  several  weeks.  And  in  December, 
1879,  another  similar  attack  prostrated  her,  with  pain  and  hemorrhage, 
lasting  until  the  middle  of  March,  1880. 

During  the  whole  continuance  of  this  attack  she  was  in  the  Woman's 
Hospital,  of  the  State  of  Illinois,  under  my  immediate  supervision. 
During  the  early  part  of  this  last  paroxysm,  the  uterus  was  enlarged 
until  it  extended  two  inches  or  more  above  the  umbilicus,  and  occu- 
pied all  of  the  central  and  lower  portion  of  the  abdomen  to  within  two 
inches  of  the  crest  of  the  iliac  bones  on  either  side. 

Since  the  subsidence  of  the  symptoms,  the  uterus  and  tumor  have 
decreased  about  one-fourth. 

The  tumor  is  now  somewhat  elastic,  whereas  during  the  early  part 
of  the  paroxysm  it  was  very  firm. 

The  health  of  the  patient  is  so  very  poor  and  uncertain,  and  she  so 
dreads  the  suffering  she  experiences  during  the  attack,  that  she  now 
begs  the  removal  of  the  entire  mass.     She  is  an  intelligent  woman, 

*  Obstetric  Journal  of  Great  Britain,  October,  1876,  p.  430. 


676  SURGICAL    TREATMENT. 

and  has  made  herself  quite  conversant  Avith  her  condition  and  the 
extreme  measures  sometimes  resorted  to  for  relief,  and  is  entirely  will- 
ing to  abide  the  consequences  of  the  operation. 

I  am  deterred  from  indulging  her  -\vish  for  the  removal  of  the  tumor 
by  hysterectomy,  by  the  apparent  general  and  very  firm  adhesions 
of  the  front  surface  of  the  tumor  to  the  anterior  walls  of  the  abdomen. 

Whether  this  patient's  life  has  been  prolonged  by  oophorectomy  or 
not,  of  course  no  one  can  know.  That  her  condition,  so  far  as  suffer- 
ing is  concerned,  has  been  greatly  improved,  I  think  any  one  witness- 
ing her  agony  and  prostration  during  a  paroxysm  would  believe.  And 
while  I  have  no  doubt  of  the  thoroughness  and  skill  of  the  operation, 
I  must  say  I  believe  it  to  be  a  partial  failure. 

In  presenting  these  reflections  on  the  difference  between  the  effect 
of  a  natural  change  of  life  and  oophorectomy  upon  fibrous  tumors  of  the 
uterus,  I  do  not  wish  to  be  understood  as  opposing  oophorectomy. 
They,  however,  make  me  hesitate  to  give  an  unconditional  adhesion 
to  the  practice,  even  where  in  our  present  knowledge  it  would  seem 
indicated. 

The  effect  of  removing  the  ovaries  for  intolerable  and  incurable 
cases  of  oophoro-neuroses,  is  quite  another  thing ;  for  then  we  remove 
the  cause  of  the  disease,  or  rather  the  symptoms;  because,  aa  they  are 
the  organic  origin  of  the  neuroses,  their  condition  is  the  disease,  and 
like  amputating  a  limb,  that  is  incurabl}'-  diseased,  to  get  rid  of  the 
symptoms,  we  cut  off  the  ovaries  for  the  same  purpose. 

There  is  another  side  to  this  subject,  however,  and  that  is,  the  general 
condition  of  the  patients,  who  are  the  subjects  of  these  nervous  symp- 
toms, in  such  as,  in  part,  to  account  for  their  suffering.  And  we 
sometimes  find  that  a  radical  change  in  the  circumstances  under  which 
they  live,  will  dispel  their  trouble.  Instances  of  this  kind  must  have 
fallen  under  the  observation  of  most  practitioners  of  long  experience. 
Muscular  labor,  outdoor  exercise,  and  the  loss  of  luxuries,  when  brought 
by  inexorable  bad  fortune,  have  done  wonders,  in  the  way  of  remov- 
ing oophoro-neuroses. 

Then  the  question  comes  up,  whether  we  ought  to  spay  our  patient 
or  prescribe  and  enforce  the  proper  amount  and  kind  of  primitive 
living  necessary  to  revolutionize  her  nervous  functions. 

The  former  course  is  the  easiest,  and,  I  am  sorry  to  say,  most  accept- 
able to  some  patients. 

The  following  are  Dr.  Battey's*  conclusions  as  to  the  proper  cases 
for  oophorectomy : 


*  "Wliat  is  the  Field  for  Battel's  Operation  ?"  A  paper  read  before  the  American 
Gynecological  Society  in  Cincinnati,  September  1st,  1880,  by  Dr.  Robert  Battey,  of 
Rome.  Georgia. 


OOPHORECTOMY.  677 

'  "It  is  not  a  question  as  to  whether  extirpation  of  the  ovaries  sliall  be  resorted  to,  or 
whether  valerian  or  asafcetiria  be  given,  or  resort  be  had  to  any  other  known  resources 
of  gynecology,  but  the  case  must  be  narrowed  down  to  this,  as  the  only  expedient 
available." 

The  following  are  the  classes  in  which  he  regarded  the  operation  as 
justifiable  : 

"  1st.  Congenital  absence  of  the  uterus,  coupled  with  ovulation,  in  which,  at  the  men- 
strual epochs,  there  are  violent  vascular  and  nervous  perturbations,  that  are  either 
dangerous  to  life  or  destructive  to  the  health  and  happiness  of  the  patient.  2d.  Com- 
plete occlusion  of  the  utero-vaginal  canal.  3d.  Certain  cases  of  menstruo-mania,  abso- 
lutely incurable  by  any  of  the  known  resources  of  medical  science  or  art.  4th.  Ovarian 
epilepsy.  5th.  Certain  cases  of  chronic  ovaritis.  6th.  Certain  cases  of  amenorrhoea. 
7th.  Ovarian  hernia.  8th.  Submucous  or  interstitial  fibroids.  9th.  Incurable  flexion 
of  the  uterus.     10th.  Csesarean  section." 

This  last,  of  course,  means  cases  in  which  patients  cannot  be  deliv- 
ered per  vias  naturalis. 

In  deciding  whether  or  not  he  should  advise  the  operation,  he  asks 
himself  three  questions : 

'•1st.  Is  this  a  grave  case?  2d.  Is  it  a  case  incurable  by  any  other  known  resources 
of  medical  and  surgical  art?     3d.  Is  it  curable  by  the  menopause?" 

If  all  are  satisfactorily  answered  in  the  affirmative,  he  regarded  the 
ease  as  a  proper  one  for  the  operation  known  as  Battey's.  If  either 
question  cannot  be  answered  satisfactorily,  he  regarded  the  case  as 
one  in  which  the  operation  is  not  justifiable.* 

While  these  positions  are  not  all  as  definitely  put  as  they  ought  to 
be  in  a  matter  of  so  great  importance,  one  thing  is  made  plain  by 
them,  and  that  is,  Dr.  Battey  regards  the  operation  as  a  last  resort. 

We  are  not  yet  able  to  do  more  than  practice  Battey's  operation 
according  to  the  imperfect  light  we  have  upon  the  subject,  because  it 
is  the  only  available  means  of  relief  we  can  command.  By  intelli- 
gently watching  effects  we  will  be  able  after  awhile  to  arrive  at  defi- 
niteness  of  indications  for  its  employment.  Too  much  latitude  is 
given  by  some  and  too  little  by  others,  and  it  will  require  much 
more  observation  before  all  shall  agree  upon  the  question — when 
shall  we  resort  to  this  operation  ?  The  final  position  of  the  profes- 
sion must  come  as  the  result  of  an  earnest  and  sober  estimate  of  col- 
lected facts ;  sentiment  should  play  no  part  in  the  matter.  The 
attempt  to  settle  this  question  by  facetious  reveries  as  to  the  value 
of  the  ovaries  and  supercilious  flings  at  gynecologists,  has  become 
monotonous  and  contemptible.  Until  sufficient  knowledge,  derived 
from  careful  observation,  is  obtained  to  guide  the  practitioner  defi- 

*  American  Journal  of  Obstetrics,  October  No.,  1880. 


678  SUEGICAL   TREATMENT. 

nitely  to  unimpeachable  conclusions,  we  must  do  as  the  members  of 
the  profession  have  heretofore  always  been  obliged  to  do — be  governed 
by  what  light  we  have.  If  we  do  this  honestly  we  will  be  in  the  line 
of  our  plain  duty. 

There  are  some  indications  for  oophorectomy  upon  which  well- 
informed  gynecologists  agree :  1st.  The  absence  or  rudimentary 
development  of  the  uterus,  with  such  severe  dysmenorrhoeal  symp- 
toms as  greatly  to  impair  the  health  and  usefulness  of  the  patient. 
2d.  Demonstrable  structural  lesions  of  the  ovaries,  with  symptoms  ot 
such  gravity  as  to  entail  hopeless  invalidism  upon  the  subject  of 
them.  3d.  Incorrigible  displacements  of  the  ovaries,  with  invalidism. 
4th.  The  presence  of  a  solid  or  cavernous  fibrous  tumor  of  the  uterus, 
attended  with  uncontrollable  hemorrhage,  or  causing  dangerous  pres- 
sure. 

Most  other  indications  are  subjects  of  discussion  ;  while  some  of 
them  are  sufficient  to  induce  some  men  to  operate,  others  would  hesi- 
tate, if  they  did  not  reject  them  as  insufficient.  Such  are  oophoro- 
mania,  oophor-epilepsy  and  oophoralgia,  nymphomania,  and  perhaps 
others.  These  names  are  according  to  Battey,  and  doubtless  correct. 
The  presence  of  any  of  the  symptoms  enumerated  in  this  last  series 
of  indications  is  only  conditionally  a  reason  for  operation.  If  the 
symptoms  can  be  traced  to  ovarian  irritation,  cannot  be  cured  by  any 
other  mode  of  treatment,  and  are  sufficiently  severe  to  disqualify  the 
patient  for  the  enjoyment  of  happiness  and  the  discharge  of  useful 
duties,  the  indication  is  clearly  made  out.  It  is  but  fair  to  admit  that 
there  may  be,  and  probably  are,  cases  of  mania  and  epilepsy  of  the 
type  of  description  contemplated  in  this  connection,  that  do  not  de- 
pend upon  ovarian  irritation.  And  no  doubt  there  are  cases  which 
have  their  origin  primarily  in  ovarian  irritation  and  are  perpetuated 
after  this  cause  is  removed,  by  centric  conditions  resulting  from  the 
powerful  and  frecjuently  repeated  reflex  impressions  to  which  the  ner- 
vous centres  have  been  subjected.  These  admissions,  however,  cannot 
exclude  ovarian  irritation  as  a  frequent  cause  of  oophoro-mania  and 
epilepsy. 

Is  there  any  essential  difference  between  the  epileptic  and  maniacal 
seizures  caused  by  ovarian  irritation,  and  those  arising  from  other 
causes?  I  am  not  disposed  to  answer  this  question,  but  would  sug- 
gest that  so  far  as  the  brain  is  concerned,  the  condition  is  probably 
the  same  as  it  is  in  other  forms  of  reflex  mania  or  epilepsy.  In  the 
one  case  the  aura  arises  in  the  ovary,  and  in  the  other  some  other 
diseased  point. 

Operation. 

The  operation  as  a  laparotomy  is  in  the  main  features  similar  to 
abdominal  section  for  other  purposes.  It  may  not  be  unprofitable, 
however,  to  pass  the  different  steps  of  the  operation  in  review. 


OOPHOEECTOMY.  679 

The  preparation  of  the  patient's  room  and  other  surroundings 
should  be  as  thoroughly  antiseptic  as  possible,  and  the  strictest  pre- 
cautions taken  to  avoid  all  risks  of  septic  exposure  from  every  source. 
The  bowels  should  be  well  evacuated  ten  or  twelve  hours  before  the 
operation ;  as  when  there  is  much  fecal  matter  or  gas  in  them  the 
intestines  will  be  very  much  in  the  way  and  prove  a  source  of  much 
embarrassment  to  the  operator.  To  still  further  secure  an  empty  con- 
dition of  the  alimentary  canal  the  patient  should  entirely  abstain  from 
eating  the  meal  before  the  operation.  The  bladder  should  be  thor- 
oughly evacuated  only  a  few  minutes  before  the  ansesthetic  is  given. 

The  incision  is  made  in  the  linea  alba,  commencing  about  an  inch 
above  the  pubis  and  extending  upwards  two  inches  if  there  is  not  too 
thick  a  layer  of  adipose  tissue.  If  the  fat  is  two  inches  or  more  in 
depth,  it  may  be  lengthened  accordingly.  The  strokes  of  the  knife 
may  be  free  until  the  skin  and  fat  are  divided  down  to  the  fascia  cov- 
ering the  tendon  uniting  the  flat  muscles  of  the  abdomen.  When  this 
is  fairly  exposed  it  will  be  better  for  the  inexperienced  operator  to 
cautiously  lift  up  thin  layers  of  the  presenting  tissues  and  divide  them 
with  a  blunt-pointed  bistoury  or  scissors  until  another  adipose  layer 
is  reached.  This  fat  is  in  contact  with  the  peritoneum  and  clearly 
indicates  our  near  approach  to  that  membrane.  Before  proceeding 
further  all  hemorrhage  should  be  arrested.  When  this  is  done  we 
may  lift  the  fat  between  the  thumb  and  finger  sufficiently  to  raise  it 
and  the  peritoneum,  to  which  it  adheres,  clear  of  the  abdominal  con- 
tents and  make  an  opening  in  them  through  which  a  grooved  director 
or  the  finger  may  be  passed,  upon  which  to  enlarge  the  opening  to  the 
size  of  the  external  incision.  Looking  into  the  abdomen  we  will  gen- 
erally see  the  om.entum  covering  the  intestines,  whose  convolutions 
will  be  plainly  visible  through  it.  Sometimes  the  omentum  does  not 
extend  so  low,  and  then  the  uncovered  intestines  will  be  exposed  to 
view.  Freshly  cleaning  our  hands  we  pass  the  two  fingers  of  one 
hand  through  the  incision  down  into  the  pelvis — over  and  not  through 
the  omentum — in  search  of  the  uterus,  from  the  fundus  of  which  we 
can  easily  trace  the  Fallopian  tube  and  ovarian  ligament  to  the  ovary. 
When  there  are  no  morbid  adhesions  the  ovary  and  tube  may  be 
raised  to  the  opening  in  the  abdominal  walls  and  exposed  to  view. 
They  should  both  be  drawn  up  so  that  a  double  ligature  can  be  passed 
beneath  them  and  tied  over  either  side.  As  much  of  the  tube  should 
be  drawn  into  the  ligature  as  we  can  include  without  forcibly  stretching 
it.  In  cutting  through  the  pedicle  thus  made  we  should  be  careful  to 
remove  all  the  ovarian  stroma.  This  precaution  is  necessary  because 
the  presence  of  a  small  part  of  this  substance  may  perpetuate  the  evils 
for  which  the  operation  is  performed.  It  is  not  sufficient  to  place  the 
ligature  around  the  ligament  and  vessels  of  the  ovaries.  This,  it  would 
8eem,  does  not  prevent  ovulation.     Great  care  should  be  taken  to 


680  SUPtGICAL   TREATMENT. 

ligate  the  pedicle  so  as  to  give  room  for  the  complete  excision  of  the 
ovary  and  yet  leave  sufficient  substance  to  avoid  the  danger  of  the 
ligature  slipping  off.  In  some  cases,  after  the  incision  is  completed, 
the  operator  will  be  met  by  adhesions  of  the  omentum  to  the  bladder 
and  intestines,  or  by  the  adhesion  of  the  convolutions  of  the  latter  to 
each  other,  to  the  bladder,  or  other  organs,  in  such  a  waj^  as  to  bar  the 
entrance  to  the  cavity  of  the  pelvis.  This  will  require  careful,  gentle, 
and  patient  efforts  at  separation.  These  attempts  should  be  made  at 
the  sides  of  the  pelvis,  in  the  neighborhood  of  the  ovaries,  and  to  such 
an  extent  only  as  is  necessary  to  reach  these  organs  first  on  one  side 
and  then  the  other.  Whether  this  kind  of  obstacle  exists  or  not,  the 
ovary  and  tube  may  be  involved  in  a  mass  of  exudation  which  almost 
invests  them.  In  the  worst  forms  of  such  involvement,  whether  it  is 
not  better  to  abandon  the  attempt  to  remove,  is  a  question  of  great 
importance,  to  be  decided  by  the  circumstances  as  met  with  in  each 
case.  If  we  decide,  as  we  generally  will,  to  proceed  we  should  depend 
upon  stretching  as  much  as  possible.  Sometimes  gentle  and  perse- 
vering traction  between  the  thumb  and  finger  will  lift  them  out  of  the 
mass  sufficiently  to  pass  a  ligature  beneath  them.  We  may  greatly 
facilitate  access  to  the  ovaries  by  having  an  assistant  press  the  wall 
down  well  in  the  side  we  operate  upon,  not  n:ierely  to  draw  the  side 
of  the  incision  so  as  to  open  the  wound,  but  to  depress  the  margin  of 
it  into  the  pehds  toward  the  ovary.  If  it  becomes  necessary  to  tear 
these  organs  loose,  the  violence  should  be  over  as  small  an  area  as  pos- 
sible, and  measures  taken  to  stop  hemorrhage  if  any  occurs.  (See 
surface-ligation  as  shown  in  connection  with  Ovariotomy. )  The  length 
of  the  incision  in  cases  of  great  adhesion  should  be  increased,  and 
when  we  operate  for  the  removal  of  the  ovaries  and  tubes  in  the  pres- 
ence of  a  fibroid  tumor  of  the  uterus,  the  incision  should  be  longer 
than  in  other  cases.  The  ovaries  are  sometimes  lifted  high  above  the 
pelvis  by  the  tumor  and  may  be  found  on  the  side  of,  behind,  or 
before  it.  Less  frequently  they  are  found  near  their  normal  position. 
In  ordinary  cases  the  incision  should  be  small  and  not  large  enough 
to  admit  the  hand.  Where  there  is  plenty  of  room  to  do  so,  the  hand 
is  very  apt  to  find  its  way  into  the  abdominal  cavity,  a  practice  that 
ought  to  be  avoided  as  much  as  possible.  The  most  important  items 
in  this  operation  are  gentleness  and  avoidance  of  all  unnecessar}"  ma- 
nipulation. A  looker-on  can  give  a  pretty  good  prognosis  by  observing 
the  energy  and  amount  of  manipulation  practiced  by  the  operator. 

The  after-treatment  is  so  like  ordinary  ovariotomy  that  it  is  only 
necessary  to  refer  the  reader  to  that  subject. 

rhydcal  and  Psyclikal  Results. 

I   have   four  patients  from  whom  I  have  removed   both  ovaries, 
whom  I  occasionally  meet,  and  so  far  as  I  can  see,  and  from  explicit 


OOPHORECTOMY.  681 

assurances  given  by  them,  I  believe  they  are  not  unsexed  in  any 
other  sense  than  that  they  are  sterile,  and  do  not  menstruate.  In 
morals,  manners,  appearances,  affections,  propensities,  and  voice,  they 
remain  the  same. 

The  operation  of  removing  the  ovaries  per  vaginam  was  first  per- 
formed by  Dr.  Battey.  After  exploring  the  posterior  and  vaginal 
walls  Dr.  Battey  made  an  incision  in  the  central  line,  about  one  inch 
and  a  half  long,  and  with  his  finger  drew  the  ovaries  through  the 
opening,  ligated  them  and  cut  them  off". 

Since  then  the  operation  has  been  repeated  in  the  same  way  by 
others.  The  ovaries  have  also  been  removed  a  number  of  times 
through  the  abdominal  walls.  The  main  obstacle  to  be  met  in  the 
performance  of  the  operation  is  the  adhesions  arising  from  previous 
or  existing  inflammation.  Sometimes  this  obstacle  is  so  great  that 
the  operation  through  the  vaginal  wall  is  extremely  difficult,  and 
occasionally  quite  impossible.  In  such  cases  laparo-oophorectomy 
would  be  the  easiest  operation. 

The  incision  in  this  operation  should  be  made  in  the  same  place  as 
for  ovariotomy,  and  no  larger  than  is  necessary.  Tait  sometimes 
removes  the  ovaries  through  an  opening  an  inch  long,  but  probably 
two  inches  will  be  a  more  frequent  incision. 


CHAPTER   XL  I. 

AFFECTIONS  OF  THE  OVAEIES. 

Congenital  Atrophy. 

The  ovaries,  like  the  rest  of  the  genital  organs  of  woman,  may  be 
imperfectly  developed.  It  is  not  unusual  to  meet  with  a  woman  whose 
sexual  system  is  developed  only  to  a  degree  usually  found  to  indicate 
the  completion  of  childhood.  The  breasts  are  about  the  size  and  shape 
of  the  girl  at  twelve  years  of  age.  She  does  not  menstruate,  and  per- 
haps is  not  endowed  with  the  sexual  desires  common  to  the  sex;  and 
if  married,  fails  to  bear  children.  The  uterus,  if  examined,  is  found 
small,  as  are  also  the  clitoris,  labia  and  nympha.  In  all  the  instances 
of  this  kind  that  have  come  under  my  observation,  the  individuals 
were  otherwise  well  developed.  Xot  unfrequently,  however,  as  shown 
by  other  observers,  the  whole  person  is  deficient,  never  attaining  to 
more  than  the  stature  of  a  child.  Cases  of  the  congenital  atrophy  of 
the  ovaries  are  given  in  this  work  under  the  head  of  amenorrhoea, 
with  the  method  of  treating  the  condition.  Senile  atrophy  of  the 
ovaries  needs  no  description  in  this  place. 

Hypertrophy. 

Enlargement  of  the  ovaries  is  probably  occasionalh"  due  to  an  in- 
crease in  size  without  other  alteration  of  their  tissues.  This  is  hyper- 
trophy. It  is  supposed  to  result  from  prolonged  congestion,  causing 
hypernutrition  of  the  organ.  The  disease  is  hypothetical,  as  it  has 
not  been  demonstrated. 

More  frequently  the  enlargement  is  caused  by  an  increase  of  some 
of  the  natural  tissues  and  by  inflammatory  eflfusions.  This  last  enlarge- 
ment is,  of  course,  due  to  clu'onic  inflammations.  It  is  not  easy,  if  at 
all  practicable,  to  diagnosticate  hypertrophy  of  the  ovaries.  We  can 
generally  detect  enlargement  of  these  bodies  by  physical  examination, 
but  cannot  in  all  cases  determine  with  certainty  the  nature  of  the 
enlargement. 

Displacement. 

Their  intimate  and  firm  ligamentous  connection  with  the  fundus 
of  the  uterus  causes  them  to  partake  of  the  changes  in  the  position  of 
that  part  of  the  organ.  Thus,  when  the  fundus  rises  into  the  ab- 
dominal cavity  during  pregnancy,  the  ovaries  are  carried  up  ■\^'ith  it, 


DISPLACEMENT.  683 

and  in  very  thin  persons  they  may  sometimes  be  felt  as  small,  mov- 
able, sensitive  tumors  upon  the  side  of  the  uterus  (see  pp.  69-72). 

The  same  thing  occurs  in  some  cases  when  the  uterus  is  much 
enlarged  by  a  fibroid  tumor.  In  the  former  condition  the  displace- 
ment is  physiological,  and  does  not  ordinarily  give  rise  to  serious 
inconvenience,  unless  the  organ  is  rendered  unusually  sensitive  by 
disease.  When  the  uterus  is  retroverted  or  retroflexed,  the  ovaries 
are  displaced  to  a  greater  or  less  extent  downward  and  backward,  and 
sometimes  this  displacement  is  so  great  that  they  may  be  felt  in  the 
posterior  cul-de-sac  and  constitute  a  very  annoying  complication.  In 
fact,  this  condition  is  of  more  consequence  than  the  uterine  displace- 
ment, and  is  a  serious  barrier  to  the  correction  of  the  malposition  of 
the  uterus,  on  account  of  their  liability  to  be  compressed  by  the  in- 
strument used  to  hold  the  uterus  in  place.  But  sometimes  the  ovaries 
fall  into  this  position  without  the  uterine  deviation.  When  this  is 
the  case  there  are  likely  to  be  many  grave  symptoms,  which  are 
included  in  the  vague  and  imperfectly  understood  term  "ovarian 
irritation."  In  most  cases  of  this  nature  the  ovaries  are  the  subject 
of  some  form  of  organic  disease,  and  we  may  reasonably  doubt 
whether  the  symptoms  do  not  arise  from  the  pre-existing  disease  rather 
than  from  the  deviation  from  their  normal  position.  There  can  be 
no  doubt,  however,  that  the  displacement  may  greatly  embarrass  the 
circulation  in  them,  and  thus  contribute  still  farther  to  their  morbid 
.  condition.  In  such  cases,  the  extensive  reflex  nervous  influence 
exerted  through  the  genito-spinal  centres  awakens  a  long  chain  of 
morbid  phenomena  destructive  of  the  comfort  of  the  patient,  and 
sometimes  establishes  a  series  of  oophoro-neuroses  that  wrecks  the 
patient  mentally  and  physically. 

Finally,  I  may  say  that  rarely  these  organs  may  make  their  way 
out  through  the  inguinal  canal,  in  something  of  the  same  way  that 
the  testes  do  in  the  male.  As  there  is  no  scrotum,  however,  in  which 
they  can  find  lodgment,  they  are  arrested  at  the  upper  border  of  the 
pubis,  and  there  constitute  a  harassing  and  painful  hernia.  This 
ovarian  hernia  may  generally  be  diagnosed  from  the  omental  or  in- 
testinal hernia,  from  the  facts,  first,  that  these  two  latter  seldom  pass 
out  through  the  inguinal  ring  in  the  female,  though  frequentlj^  through 
the  femoral  ring;  second,  that  they  are  not  particularly  sensitive  to 
the  touch  unless  in  a  state  of  inflammation  from  strangulation,  while 
the  ovary  is  quite  sensitive ;  and,  third,  that  the  sensitiveness  of  the 
ovary  is  said  to  be  peculiar,  resembling  nothing  so  much  as  the  sick- 
ening sensation  experienced  upon  pressing  the  testicle,  while  the 
sensation  of  omental  or  intestinal  hernia  is  rather  the  tenderness  of 
inflammation. 

Having  referred  to  the  different  varieties  of  ovarian  displacements, 
I  desire  now  to  confine  myself  to  the  pelvic  deviations  of  position. 


684  AFFECTIONS    OF   THE    OVARIES. 

Symptoms. 

What  are  the  symptoms  of  pelvic  displacements  of  the  ovaries? 
Having  already  referred  to  them,  I  shall  be  brief  in  their  further  con- 
sideration. 

They  may  be  included  under  two  heads,  local  and  general.  The 
local  symptoms  are  not  distinctive.  They  are  pain,  weight,  or  bear- 
ing-down sensation,  sometimes  heat  in  the  pelvis,  backache,  sacral 
and  coccygeal  tenderness,  and  occasionally  radiating  neuralgia ;  there 
are  also  very  frequently,  though  not  always,  menstrual  derangements, 
but  these  local  symptoms  ma}^  be  i)roduced  by  many  of  the  disorders 
incident  to  most  of  the  pelvic  organs. 

As  to  the  general  symptoms.  They  are  quite  numerous  and  varied. 
It  is  indeed  questionable  whether  all  of  the  hystero-neuroses  should 
not  be  regarded  as  oophoro-neuroses  ;  that  is,  direct  or  indirect  morbid 
emanations  from  the  ovaries  themselves.  It  is  probably  impossible 
for  us  to  separate  the  general  symptoms  arising  from  disease  of  the 
pelvic  viscera  into  uterine,  ovarian,  vaginal,  and  vulval,  as  the  nerve- 
supply  to  these  organs  is  essentially  a  unit,  and  for  their  nervous 
manifestations  are  subject  to  the  same  presiding  centre. 

In  them  is  comprised  a  circle  of  functions  to  the  perfection  ot 
which,  soundness  in  all  of  the  organs  is  essential.  Whether  the  ter- 
rible nervous  symptoms  arising  from  certain  diseases  of  the  vulva,  the 
vagina,  or  the  uterus  can  be  reflected  upon  the  organization  in  any 
other  way  than  through  their  connection  with  the  ovaries  is  a  ques- 
tion not  yet  solved.  I  think  we  cannot  doubt,  however,  that  to 
"ovarian  irritation"  may  be  attributed  the  whole  array  of  reflex  phe- 
nomena so  frequently  noticed  in  the  wrecked  condition  of  broken- 
down  women. 

In  the  retrouterine  displacements  of  the  ovaries,  these  conditions 
are  prominent  features,  the  numerous  symptoms  often  assuming  a 
very  aggravated  form,  and  the  suffering  of  the  patient  becoming  un- 
endurable. The  general  symptoms  are  those  of  ovarian  irritation, 
and  this  is  to  be  expected,  because  the  circulation  and  the  innerva- 
tion of  these  organs  must  necessarily  be  very  much  interfered  with  by 
their  malposition. 

The  Diagnosis 

Of  these  displacements  is  not  generally  very  difficult.  When  in  the 
inguinal  canal,  an  examination  of  the  tumor,  its  shape  and  peculiar 
sensitiveness  are  both  characteristic ;  the  only  thing  for  which  it  may 
be  mistaken  is  hernia  of  the  omentum  or  intestine,  and  a  tumor 
formed  by  the  protrusion  of  either  of  these  is  more  globular,  less  firm, 
and  unless  in  a  state  of  inflammation  is  not  very  sensitive.  When 
in  the  cul-de-sac  behind  the  uterus  if  not  changed  in  shape  by  disease 
the  ovary  has  the  same  outline  as  when  naturally  situated  and  is 


CAUSES EFFECTS PROGNOSIS — TREATMENT.  685 

movable.     We  may  reach  it  by  passing  one  or  two  fingers  deep  into 
tiie  vagina  or  rectum. 

Causes. 

In  many  instances  this  displacement  is  associated  with  retroversion 
or  retroflexion  of  the  uterus,  and  is  apparently  the  result  of  the  mal- 
position of  that  organ.  In  others,  however,  the  ovaries  fall  behind 
the  uterus,  because  of  their  enlargement  and  increased  weight  from 
structural  disease.  Possibly  a  relaxed  condition  of  the  fold  in  the 
broad  ligament  in  which  it  is  contained,  may  permit  the  ovary  to 
settle  down  out  of  its  natural  position. 

Effects.       - 

Are  displacements  of  the  ovaries  always  and  necessarily  accom- 
panied by  serious  local  symptoms  or  destructive  general  disturb- 
ances? I  think  not.  Probably  every  gynecologist  of  extensive  ob- 
servation has  noticed  instances  in  which  the  ovaries  could  be  felt  in 
the  CM/-c?g-sac,  and  the  patient  experience  little  if  any  inconvenience, 
from  such  malposition.  These,  judging  from  my  own  observation, 
are  not  very  uncommon  cases. 

Why  should  some  patients  suffer  so  much  from  these  displacements 
while  others  experience  so  little  inconvenience  from  them? 

In  answering  this,  I  must  employ  a  term  that  is  not  yevy  definite, 
and  perhaps  not  always  intelligible,  "  nervous  susceptibility."  This 
nervous  susceptibility  with  some  patients  appears  to  be  a  part  of  their 
original  construction  or  "  make  up  "  if  you  please,  while  with  others 
it  is  an  acquired  condition. 

Nervous  susceptibility  and  neurasthenia,  if  not  connected  as  cause 
and  effect,  are  at  least  very  intimately  associated,  and  to  treat  these 
cases  successfully  therefore,  we  must  have  in  mind  this  item  of  ner- 
vous susceptibility  or  neurasthenia  connection. 

Prognosis. 

When  displacements  give  rise  to  symptoms  of  ovarian  irritation, 
what  is  the  prospect  of  relief? 

Such  cases  are  justly  regarded  as  very  unpromising,  but  not  neces- 
sarily incurable. 

Treatment. 

The  treatment  of  the  symptoms  attendant,  and  to  some  extent  de- 
pendent upon  displacements  of  the  ovaries,  is  sometimes  followed  by 
most  satisfactory  results.  By  treating  the  symptoms,  I  do  not  mean 
the  administration  of  medicines  for  the  relief  of  nervous  headache, 
hysterical  convulsions,  sleeplessness,  etc.,  but  the  removal  of  those 
conditions  from  the  system  which  encourage  their  manifestation. 


686  AFFECTIONS   OF   THE   OVARIES. 

Whatever  may  have  been  the  diathesis  of  our  immediate  ancestors, 
■whether  they  were  affected  by  diseases  resulting  from  hypersemia  or 
plethora  or  not,  it  is  evident  that  we  have  fallen  upon  times  when 
anaemia  or  hydrsemia  among  women  is,  to  say  the  least,  a  very  com- 
mon state  of  the  general  system.  This  is  esjDecially  the  case  with  a 
large  j)roportion  of  patients  suffering  from  ovarian  irritation,  either 
with  or  without  displacements  of  the  ovaries,  and  the  nerve  centres  in 
such  people  are  habitually  an£emic. 

Nervous  exhaustion  means  imperfect  nutrition  or  lack  of  trophic 
energy  in  the  nerve  centres.  This,  I  have  no  doubt,  is  mainly  because 
there  is  not  a  sufficient  amount  of  good,  rich  blood  circulating  through 
them. 

I  cannot  understand  how  nervous  exhaustion  can  take  place  when 
there  is  an  unfailing  supply  of  nutrition  in  these  centres,  but  it  is 
plain  that  an  exhaustion  of  supply  will  render  the  regular  working  of 
the  brain  and  spinal  cord  impossible.  It  is  blood  exhaustion,  then, 
instead  of  nerve  exhaustion. 

"What  we  want  to  do  with  these  patients  is  to  turn  them  entirely 
around  in  their  habits,  and  lead  them  to  the  adoption  of  measures 
that  will  make  them  plenty  of  blood  and  fat.  Dr.  S.  Weir  Mitchell 
has  taught  us  how  to  do  this,  and  his  system  of  managing  patients 
of  this  character  is  admirable.  It  is  not  always  practical,  nor,  indeed, 
necessary  to  adopt  his  method  as  a  whole.  This,  however,  does  not 
detract  from  its  merits.  Absolute  rest  is  necessary  only  in  cases  of 
extreme  prostration. 

In  most  cases  active  exercise  will  be  better  than  passive,  and  should 
always  be  enjoined  upon  the  patient  and  attendants.  The  exercise  in 
kind  and  quantity  should  be  prescribed  and  enforced  with  exacting 
regularity,  and  urged  by  decision  that  will  not  fail. 

The  most  important  part  of  the  treatment,  however,  is  the  regulation 
of  food,  by  which  I  mean  the  prescription  of  it  in  items  and  quantity 
from  day  to  day. 

My  routine  prescription  is  three  ounces  of  beefsteak  for  breakfast, 
with  bread  and  butter,  or  toast,  potatoes,  and  other  vegetables,  as  the 
capacity  for  digestion  will  allow;  six  ounces  of  roast  beef  or  mutton, 
bread  and  butter,  potatoes,  vegetables,  etc.,  for  dinner;  for  supper  the 
same  as  for  breakfast,  and  after  each  meal,  and  at  bedtime,  one  pint 
of  good  fresh  milk.  The  only  limit  I  would  place  upon  the  amount 
of  food  of  the  kind  I  have  indicated  is  the  capacity  of  the  stomach  to 
retain  it.  If  the  food  is  not  rejected  by  vomiting,  or  it  does  not  irri- 
tate the  bowels  enough  to  cause  diarrhoea,  I  would  not  allow  the  want 
of  appetite  nor  the  inconvenience  that  may  arise  during  digestion  to 
be  considered  as  a  reason  for  not  taking  it.  Usually  the  stomach  will 
soon  become  tolerant,  and  after  a  time,  the  enriched  blood,  circulating 
through  its  glandular  apparatus,  will  engender  a  relish  for  food,  and 


TREATMENT.  687 

the  patient  will  eat  with  pleasure.  This  intimation,  that  an  anemic 
stomach  necessarily  digests  with  difficulty,  is  intentional,  for  1  do  not 
believe  that  energetic  innervation  is  possible  unless  the  supply  of 
blood  is  sufficient  to  secure  good  digestion. 

With  this,  or  some  other  equivalent  method  of  feeding  the  patient, 
there  should  be  associated  some  plan  by  which  she  can  get  plenty  of 
fresh  air,  and  have  as  much  exercise  as  she  is  able  to  take.  The  ex- 
ercise may  be  passive  at  first,  but  as  soon  as  it  is  possible  it  ought  to 
be  active. 

Active  exercise  may  be  begun  by  having  the  patient  walk,  sup- 
ported as  much  as  necessary  by  a  strong  nurse,  but  as  soon  as  she  can 
walk  alone  the  support  should  be  withheld.  Then  it  is  not  rest, 
but  exercise,  that,  should  be  advised  in  these  cases.  Of  this  I  am 
fully  convinced  by  experiments  and  unmistakable  proofs  in  my  own 
practice. 

As  long  as  nutrition  can  be  supplied  the  patient  will  profit  by  ex- 
ercise, but  if  nutrition  is  impossible,  then  of  course  exercise  is  impos- 
sible also.  Thus  far  I  have  said  nothing  about  medicines  to  aid 
digestion  or  to  increase  nerve  force,  not  because  I  have  no  faith  in 
them,  but  because  I  believe  them  of  secondary  importance,  mere  ad- 
juvants instead  of  principals  in  the  treatment  of  this  condition  of  the 
system. 

I  could  cite  a  number  of  instances  in  Avhich  this  course  of  manage- 
ment averted  the  dangers  and  mutilation  of  the  more  heroic  treatment 
of  castration,  by  establishing  a  vigorous  and  tolerant  condition  of  the 
nerve  system,  and  thus  curing  ovarian  irritation.  These  suggestions 
are  applicable  to  cases  other  than  displacements  of  the  ovaries  in 
which  there  is  ovarian  irritation. 

As  to  the  management  of  the  displacement.  In  some  few  cases, 
when  the  ovaries  are  borne  down  by  a  displaced  uterus,  we  may  oc- 
casionally correct  the  displacement  so  far  as  to  greatly  improve  the 
circulation  of  these  organs,  and  thus  remove  a  great  element  in  ova- 
rian distress.  This,  of  course,  is  done  by  correcting  the  displacement 
of  the  uterus,  by  proper  means  of  support,  as  a  well-adjusted  pessary. 

In  the  cases,  however,  in  which  the  symptoms  are  the  most  grave 
— retroversion  and  retroflexion  of  the  uterus, — the  location  of  the 
ovaries  in  the  cul-de-sac  by  the  side  of  the  fundus  renders  the  satisfac- 
tory adjustment  of  the  pessary  almost  impossible,  as  the  instrument 
is  pretty  certain  to  cause  pressure  upon  these  sensitive  organs,  and 
thus  become  intolerable.  We  ought  not  to  despair  of  accomplishing 
the  object,  however,  until  we  have  exhausted  our  ingenuity  in  mechan- 
ical appliances  for  this  purpose. 

When  every  other  measure  fails  either  to  render  the  condition  of  the 
patient  bearable,  or  save  her  from  becoming  a  mental  and  physical 
wreck,  we  still  have  the  resource  furnished  us  by  Dr.  Battey,  namely, 


688  AFFECTIONS   OF   THE   OVARIES. 

the  removal  of  these  organs.  In  taking  the  consequences  of  this 
operation,  however,  we  should  remember  that  it  is  a  dangerous  one, 
and  that,  if  successful,  it  unsexes  our  patient  in  the  sense  that  she  is 
at  least  barren  for  all  future  time.  When  the  ovaries  are  displaced  so 
as  to  occupy  the  inguinal  canal,  the  operation  for  removing  them  is 
less  hazardous  than  when  in  the  pelvic  cavity,  and  for  that  reason 
may  be  resorted  to  with  less  hesitation. 

Acute  Ovaritis. 

Acute  inflammation  of  the  ovaries,  in  connection  with  local  perito- 
nitis, or  inflammation  of  the  cellular  tissue  in  the  pelvis,  is  not  an 
uncommon  affection.  As  simple,  uncomplicated  disease,  however,  it 
is  conceded  to  be  of  infrequent  occurrence.  Post-mortem  examina- 
tions reveal  the  existence  of  inflammation  of  the  ovaries, as  a  compli- 
cation of  inflammation  of  the  surrounding  tissue,  in  all  stages,  from 
mere  phlogistic  hypera?mia  to  destructive  suppuration.  In  such  in- 
stances it  is  involved  in  the  general  mass  of  disease.  This  occurs  after 
abortion,  labor  at  full  term,  and  even  in  the  non-puerperal  condition, 
as  the  result  of  cold.  As  ovaritis  in  this  connection  is  a  disease 
causing  no  separate  symptoms,  and  recjuiringno  other  treatment  than 
is  necessary  for  the  cure  of  the  inflammation  accompanying  it,  all  that 
is  requisite  to  say  upon  the  subject  will  be  found  under  the  head  of 
perimetj-itis. 

As  the  result  of  the  infrequent  occurrence  of  ovaritis  in  an  uncom- 
plicated state,  our  knowdedge  of  it  is  very  meagre,  many  experienced 
practitioners  never  having  recognized  it.  The  intense  interest  the 
profession  now  feels  and  manifests  in  diseases  of  women  will  soon  lead 
to  a  clearer  understanding  of  this  subject. 

The  following  case  is  the  nearest  approximation  to  simple  acute  in- 
flammation of  the  ovaries  ever  observed  by  the  author : 

"January  5th,  1872,  I  was  called  to  see  Mrs.  S.,  widow,  aged  thirty-five  years.  She 
is  the  mother  of  three  children,  the  youngest  of  whom  is  eight  years  old.  She  had 
been  attacked  fourteen  days  before  with  pain  in  the  hypogastric  and  iliac  regions; 
chill,  nausea,  headache,  and  great  nervous  excitement.  Fever  succeeded  the  chill,  and 
the  nausea  was  sometimes  accompanied  by  vomiting.  The  pain  continued,  and  was 
aggravated  by  the  erect  or  sitting  posture.  She  was  attended  by  a  homoeopathic  prac- 
titioner, and  after  a  few  days  improved  until  she  was  able  to  sit  up  a  jiart  of  the  time  ; 
but  the  pail),  accompanied  with  tenderness  upon  pressure  in  the  iliac  region,  contin- 
ued in  a  subdued  degree.  Upon  the  13th,  about  10  p.m.,  after  having  exerted  herself  . 
too  much,  she  had  another  chill,  with  an  aggravation  of  the  symptoms.  In  the  morn- 
ing, when  I  was  called,  I  found  her  vomiting,  and  unable  to  retain  anything  but  cold 
water.  She  had  headache,  with  pain  and  tenderness  in  both  iliac  regions.  There  was 
no  tumefaction.  The  pulse  was  110  to  the  minute;  the  tongue  was  coated  white;  the 
mouth  dry,  and  other  febrile  symptoms  usual  in  moderate  attacks  of  acute  inflamma- 
tion were  present.  The  attack  had  occurred  at  the  time  the  menstrual  flow  was  subsid- 
ing, and  was  attributed  to  exposure  after  being  overheated  and  fatigued.     At  the  time 


CHRONIC    OVARITIS — OVARIAN    IRRITATION.  689 

I  saw  her  there  was  no  discharge  from  the  vagina ;  the  passage  of  the  urine  gave  her 
pain  of  a  burning  character,  and  she  suffered  pain  also  in  passing  the  fseces.  Upon 
examining  per  vaginam  with  the  finger  I  could  feel  both  ovaries  prolapsed  and  tender. 
The  uterus  was  prolapsed  somewhat ;  also  swollen  and  tender  to  the  touch.  Upon 
making  pressure  in  the  hypogastric  region  the  patient  complained  of  but  little  tender- 
ness. Downward  pressure  in  the  iliac  region  caused  more  pain,  and  increased  the  sen- 
sations of  tenderness  in  the  pelvis.  The  ovaries,  as  felt  through  the  vagina,  were 
tender,  movable,  and  appeared  to  be  three  times  their  natural  volume.  The  patient 
complained  of  increased  nausea  when  they  were  touched  in  the  examination.  I  found 
no  difficulty,  by  using  the  fore  and  middle  fingers,  in  examining  them  thoroughly  and 
recognizing  their  shape  and  size.  The  diagnosis  was  moderate  inflammation  of  the 
uterus,  with  more  acute  inflammation  of  the  ovaries.  The  patient  informed  me  that 
she  was  not  aware  of  being  the  subject  of  chronic  inflammation  of  the  uterus,  as  she 
had  not  previously  suffered  from  pelvic  pain  or  inconvenience,  indicating  chronic  dis- 
ease of  any  kind  about  the  uterus  or  ovaries.  There  did  not  seem  to  be  local  perito- 
nitis or  cellulitis,  and  but  slight  metritis.  The  bladder  was  irritable,  and  the  vagina 
slightly  tender. 

"  Treatment. 

"  Four  grains  of  calomel  were  given,  and  succeeded  in  eight  hours  by  a  saline  ca- 
thartic. Poultices  were  applied  to  the  hypogastric  region,  and  the  patient  was  ordered 
to  keep  quiet  in  the  recumbent  posture.  The  cathartics  operated  well,  and  relieved 
much  of  the  pain  and  suffering.  One-fourth  of  a  grain  of  morphia  enabled  her  to  rest 
with  some  degree  of  comfoi-t.  When  the  pain  returned  the  morphia  was  repeated,  and 
thus  continued  when  necessary  for  the  pain.  The  bowels  were  kept  soluble  by  the 
administration  of  a  fluidounce  of  the  saturated  solution  of  citrate  of  magnesia.  B7 
continuing  this  course  of  treatment  for  six  or  seven  days  the  inflammation  was  sub- 
dued, and  convalescence  was  fairly  established.  In  three  or  four  weeks  she  was 
entirely  well,  and  still  remains  so." 

Chronic  Ovaritis — Ovarian  Irritation. 

An  extensive  array  of  grave  symptoms  have  for  a  long  time  been 
imputed  to  morbid  conditions  of  the  ovaries  ;  and  while  our  informa- 
tion is  yet  meagre  as  to  the  exact  nature  of  the  pathological  changes 
in  the  ovaries,  and  their  relation  to  the  symptoms,  I  think  it  may  be 
said  that  within  a  few  years  past  our  knowledge  in  these  matters  has 
been  decidedly  advanced.  This  advancement  is  mainly  attributable 
to  the  recent  practice  of  removing  the  ovaries  as  a  therapeutic  meas- 
ure. The  efforts  to  define  by  terms  the  morbid  conditions  of  the 
ovaries  when  found  diseased,  so  far  as  I  know,  have  not  resulted  in 
anything  of  much  value.  When  removed  by  the  surgeon,  statements 
as  to  their  condition  have  been  too  vague  to  convey  to  the  reader  an 
accurate  idea.  Almost  everything  as  to  ovarian  pathology  has  yet  to 
be  determined. 

In  venturing  to  place  the  above  heading  to  this  section,  I  may  be 
subject  to  criticism,  and  possibly  correction  by  some  one  better  in- 
formed upon  the  subject.  It  will  probably  be  found  that  the  reflex 
symptoms  may  be  caused  by  more  than  one  pathological  condition  of 

these  organs. 

44 


690  AFFECTIONS   OF   THE    OVAEIES. 

Mr.  Lawson  Tait  in  his  late  work  on  Diseases  of  the  Ovaries  has 
described  hypersemia  and  chronic  ovaritis. 

In  many  cases  in  which  the  nervous  and  other  disturbances  were 
sufficient  to  require  oophorectomy,  a  common  condition  and  one  fre- 
quently found  in  my  own  cases,  was  an  unusual  number  of  cysts, 
doubtless  from  ovisacs.  And  judging  from  such  examination  as  I 
could  make,  these  cysts  contained  the  same  kind  of  albuminoids  that 
are  found  in  large  ovarian  cysts.  I  believed  them  to  be  nothing  more 
nor  less  than  ovisacs  developed  prematurely  and  imperfectly  (imper- 
fectly in  reference  to  both  the  contents  and  containing  tissues),  and 
to  be  the  result  of  a  hypergenetic  influence  in  the  ovaries  produced  by 
long-continued  hyperemia. 

Dr.  Goodell*  thinks  that  sometimes  the  inflammation  affects  the 
stroma  more  than  the  follicles  and  the  converse.  However  this  may 
be,  there  is  often  hypertrophy  of  both  these  tissues.  I  say  hyper- 
trophy because  I  know  of  no  more  appropriate  term.  It  is  not,  how- 
ever, simple  increase  of  growth  in  either  of  these  tissues,  because  the 
form  of  nutrition  in  them  is  not  normal.  In  the  stroma  the  increase 
is  inflammatory  deposit,  and,  as  before  said,  the  fluid  in  the  follicles 
while  it  somewhat  resembles,  it  is  not  identical  with  their  normal 
contents. 

Etiology. 

Without  further  discussing  the  subject  of  the  nature  of  the  changes 
in  the  ovaries  to  which  the  term  chronic  ovaritis  is  here  applied,  I 
think  we  will  find  reason  to  believe  in  the  correctness  of  it  in  the 
more  frequent  causative  conditions.  Scarcely  any  observer  will  doubt 
that  by  far  the  greatest  number  of  instances  succeed  the  acute  form, 
and  are  accompanied  b}'  unquestionable  inflammatory  changes  in  the 
surrounding  organs  and  tissues.  Both  acute  and  chronic  ovaritis  are 
generally  secondary ;  the  inflammation  invades  the  ovaries  from  con- 
tiguous parts,  as  the  broad  ligaments,  peritoneum,  and  especially  the 
Fallopian  tubes.  It  is  now  generally  believed  that  gonorrhoeal  in- 
flammation, by  passing  through  the  tubes,  reaches  the  ovaries.  Many 
cases  arise  no  doubt  during  the  progress  of  the  continued  fevers.  I 
think  also  that  instances  of  acute  inflammation  in  the  pelvis  and 
lower  abdomen,  causing  ovaritis,  are  often  mistaken  by  careless  ob- 
servers and  reported  for  typhoid  fever.  Whether  there  is  any  con- 
siderable tendency  to  ovaritis  in  the  eruptive  or  rheumatic  fevers,  as 
asserted  by  Mr.  Tait,  I  do  not  know.  Excessive  and  prolonged  sexual 
excitement,  the  rigid  discipline  at  some  of  the  more  strict  academies 
and  other  schools,  constipation,  and  in  fact  anything  that  causes  pro- 
longed hypersemia  of  the  pelvic  organs,  will  affect  the  ovaries  in  this 
way. 

*  Pepper's  System  of  Medicine. 


'SYMPTOMS.  691 


Symptoms 


These  are  local,  general  and  fanctional.  Prominent  among  the 
local  is  pain  in  the  region  of  the  ovaries  radiating  into  the  back,  up 
the  sides,  and  down  the  limbs.  If  the  disease  is  confined  to  one  of 
the  organs,  the  pain  and  suffering  may  be  manifest  on  that  side  alone. 
Pain  in  the  course  of  the  anterior  crural  or  sciatic  nerve  may  be  the 
most  prominent  local  symptom.  Not  unfrequently  the  pelvic  pain 
will  be  increased  at  the  time  of  menstruation,  constituting  ovarian 
dysmenorrhoea. 

There  is  no  doubt  that  this  affection  produces  decided  effects  upon 
the  functions  of  the  organs  of  generation,  causing  sterility,  menor- 
rhagia,  amenorrhoea,  etc. ;  also  the  abortive  development  of  the  ovi- 
sacs, as  shown  by  their  arrest  of  growth  and  their  immature  contents, 
the  discharge  of  imperfect  ova,  etc.  I  have  already  expressed  myself 
as  believing  that  the  numerous  cysts  formed  upon  the  ovaries  are  im- 
perfectly developed  ovisacs,  the  imperfections  consisting  mainly  in 
arrest  of  development  in  both  the  involucra  and  their  contents.  As 
there  is  no  question  of  the  continuous  impression  of  the  ovaries  on 
the  uterus  regulating  its  constitutional  changes  and  functions  in 
health,  so  I  believe  that  when  morbid  their  impression  will  be  vicious. 
Facts  adduced  by  Mr.  Tait  go  far  towards  proving  that  when  there  is 
chronic  hyperasmia  of  the  ovaries,  there  is  the  same  condition  in  the 
uterus,  and  that  this  gives  rise  to  menorrhagia ;  also  that  when  the 
inflammation  has  reached  the  stage  of  induration,  amenorrhoea  re- 
sults. This  is  but  another  expression  of  the  principle  that  the  gen- 
erative organs  are  so  closely  bound  together  by  the  same  set  of  nerves 
and  vessels  that  the  condition  of  all  of  them  is  apt  to  be  very  much 
alike,  anaemic,  hypersemic,  etc. 

The  general  symptoms  are  manifested  in  and  through  the  nervous 
system,  including  the  brain  and  spinal  cord.  In  fact  it  is  the  kind 
and  degree  of  disturbance  in  the  nervous  centres  that  constitutes  one 
of  the  most  important  features  in  our  estimate  of  the  gravity  of  ovarian 
disease.  The  nervous  symptoms  are  so  varied  that  it  is  difficult  to 
enumerate,  much  less  describe  them. 

I  would  refer  the  reader  to  the  chapters  on  hysteropathy  for  a  gen- 
eral view  of  the  symptoms  of  disease  of  the  genital  organs,  believing 
that  these  symptoms  would  fairly  represent  those  occurring  in  ovarian 
as  well  as  uterine  disease.  With  reference  to  the  nervous  symptoms, 
mentioned  in  those  chapters,  the  more  grave  are  now  almost  uni- 
versally attributed  to  ovarian  disease,  and  no  doubt  this  is  correct. 
Such  symptoms  are  convulsions  of  varied  intensity,  and,  mental  de- 
rangements. When  the  convulsions  are  epileptiform  they  are  called 
hystero-epilepsy,  but  perhaps  ought  to  be  denominated  oophoro- 
epilepsy.     As  I  have  witnessed  them  in  their  severer  forms  they  re- 


692  AFFECTIONS    OF    THE    OVARIES. 

semble  epilepsy  so  closely  that  I  have  been  unable  to  distmguish  be- 
tween them,  and  why  may  they  not  be  true  epilepsy  and  yet  be  of 
ovarian  origin?  As  an  aura  may  originate  in  a  wound,  why  may  it 
not  begin  in  a  diseased  ovary  ? 

One  patient  of  mine  who  had  unquestionable  epileptic  seizures 
which  lasted  for  many  years  was  cured  by  having  both  ovaries  re- 
moved. One  ovary  was  included  in  a  large  ovarian  tumor,  and  the 
other  was  found  occupied  by  numerous  small  degenerate  cysts. 

This  hystero-epilepsy  often  results  in  great  impairment  of  the  mind, 
in  fact  this  danger  is  one  of  the  justifying  conditions  of  oophorec- 
tomy. Mental  derangement,  however,  does  not  always  come  about  as 
a  result  of  long-continued  convulsions,  but  often  seems  to  be  a  more 
direct  consequence  to  ovarian  disease.  One  of  the  tests  usually  applied 
as  proof  of  ovarian  origin  is  the  repetition  or  aggravation  of  the  attacks 
at  the  time  of  the  menstrual  period.  There  is  generally  something  of 
a  correspondence  of  this  kind,  but  I  think  not  always;  for  the  parox- 
vsms  may  occur  at  regular  times  between  the  menstrual  periods. 

Diagnosis. 

As  the  ovaries  in  a  state  of  inflammation  are  larger  and  heavier 
than  natural,  they  not  infrequently  come  within  reach  of  the  finger 
in  vaginal  touch.  When  not  enlarged  or  somewhat  displaced,  it  may 
be  very  difficult  for  the  physician  to  demonstrate  to  his  satisfaction 
what  their  condition  is.  When  they  are  down  within  reach  of  the 
finger  in  the  vagina  their  shape,  size  and  sensitiveness  may  be  to  a 
certain  extent  ascertained.  The  roughness  and  unevenness  caused  by 
cystic  degeneration  when  present  may  generally  be  appreciated.  A 
perfectly  normal  ovary  ought  not  to  be  very  sensitive,  and  hence  I 
regard  tenderness  as  a  sign  of  inflammation.  In  very  thin  persons, 
by  the  bimanual  examination,  the  ovary  can  often  be  felt  when  in 
situ.  They  are  sometimes  reached  through  the  rectum,  and  when  ex- 
actitude in  diagnosis  is  important,  two  fingers  or  the  half  hand  should 
be  introduced  into  the  rectum,  when  the  ovaries  may  be  brought 
under  inspection.  Another  item  of  great  importance  in  the  diagnosis 
is  as  to  whether  the  grave  secondary  symptoms,  such  as  mental  de- 
rangement, convulsions,  etc.,  depend  on  ovarian  irritation,  or  disease 
of  the  nervous  centres  themselves.  A  few  very  important  considera- 
tions are:  1st.  Is  there  evident  ovarian  disease  of  a  serious  character 
present?  2d.  Have  the  nervous  disorders  made  their  appearance 
since  the  establishment  of  the  pelvic  trouble?  3d.  Are  the  nervous 
symptoms  aggravated  at  or  near  the  menstrual  period,  or  are  they 
worse  at  some  regular  period  during  the  menstrual  interval?  4th.  Is 
there  an  absence  of  hereditary  tendency  to  diseases  of  the  brain  ?  An 
affirmative  answer  to  all  these  questions  makes  the  probability  of 
their  dependence  on  disease  of  the  ovaries  quite  strong. 


PROGNOSIS — COMPLICATIOXS — TREATMENT.  693 

Prognosis. 

Is  the  prognosis  of  chronic  ovaritis  so  grave  as  we  have  been  in  the 
habit  of  considering  it  ?  I  think  not.  On  the  contrary,  I  believe  it 
is  often  cured,  and  more  frequently  the  suffering  of  the  patient  is 
ameliorated  until  the  menopause  comes  to  her  relief.  The  prognosis 
in  those  serious  cases  where  the  nervous  centres  are  so  severely 
affected  that  their  functions  are  threatened  with  permanent  disorder 
may  be  regarded  as  desperate  ;  but  these  are  fortunately  not  the  most 
common  form.  The  prognosis  is  rendered  desperate  because  the 
reflex  effects  of  ovarian  irritation  are  destroying  the  patient  so  rapidly 
that  we  cannot  wait  for  the  slow  operation  of  a  medicinal  course  of 
treatment,  and  hence  are  obliged  to  resort  to  surgical  measures.  There 
are  a  great  many  cases  where  the  morbid  conditions  do  not  produce 
these  symptoms  and  consequently  do  not  demand  such  radical  means 
of  relief.  In  all  grades  of  the  disease  the  cure  is  slow.  It  is  usual  to 
consider  the  ansemia  and  nervous  prostration  as  the  direct  effects  of 
the  morbid  ovarian  impression,  but  I  believe  that  the  degeneration  of 
this  structure  is  often  the  consequence  of  long  exhausting  and  vitiat- 
ing general  conditions. 

Complications. 

Chronic  ovarian  inflammation  is  nearly  always  accompanied  with 
inflammation  in  other  organs  or  tissues  of  the  pelvis.  The  most  com- 
mon are  local  peritonitis,  cellulitis  and  salpingitis.  But  the  uterus 
very  frequently  is  also  implicated.  Sometimes  there  is  displacement 
of  the  uterus  and  ovaries,  the  latter  lying  under  the  retroverted  or 
retroflexed  womb.  When  the  erect  posture  causes  them  to  be  pressed 
upon  painfully,  and  when  they  are  in  a  position  to  be  seriously  dis- 
turbed during  coitus,  the  grave  nervous  symptoms  so  frequently 
present  stand  in  the  relation  of  consequences  rather  than  complica- 
tions. 

Treatment. 

The  treatment  will  be  greatly  modified  by  the  stage  of  the  disease 
and  intensity  of  the  reflex  symptoms.  Until  the  functions  of  the 
nervous  centres  are  very  much  disturbed,  we  may  depend  upon  gen- 
eral and  gynecological  treatment  with  the  hope  of  effecting  a  cure. 
When,  however,  there  is  either  incipient  or  established  insanity,  epi- 
leptic or  hystero-epileptic  convulsions,  and  especially  if  the  disturb- 
ance to  the  brain  usually  brought  about  by  these  affections  is  increas- 
ing, we  must  regard  surgical  measures  as  essential  to  a  cure.  Mr.  Tait 
mentions  another  symptom  as  being  equally  unmanageable  without 
surgical  measures,  viz.,  excessive  and  obstinate  menorrhagia.  Possi- 
bly other  conditions  connected  with  chronic  ovaritis  may  as  urgently 
demand  oophorectomy,  but  I  think  they  must  be  very  few.     In  those 


694  AFFECTIONS    OF    THE    OVARIES. 

cases  in  which  a  multitude  of  derangements  of  minor  importance 
exist,  and  in  most  of  which  nervous  prostration  is  predominant, 
we  may  reasonably  expect,  if  not  a  complete  cure,  very  great  benefit 
from  judicious  general  treatment.  One  object  greatly  to  be  desired  is 
improvement  of  the  general  health.  In  bringing  this  about  we  do 
not,  as  might  be  supposed,  merely  palliate  the  sufferings  of  the  pa- 
tient by  making  her  better  able  to  bear  them,  but  we  create  re- 
cuperative energy.  An  improvement  in  the  condition  of  the  blood 
and  nerve  force  is  necessary  for  the  cure  of  any  chronic  disease.  A 
Avoman  cannot  be  cured  of  chronic  ovaritis  while  in  a  state  of  great 
nervous  prostration  or  profound  ansemia,  and  the  removal  of  these 
complications  goes  a  long  way  toward  the  cure.  The  systematic  feed- 
ing, massage,  electricity,  and  mental  rest  so  admirably  taught  and  prac- 
ticed by  Dr.  Weir  Mitchell,  forms  an  excellent  method  of  inaugurating 
the  treatment  of  these  cases.  This  followed  up  by  travel  when  that 
can  be  indulged  in  will  often  be  sufficient  to  restore  the  patient. 
When  neither  of  these  are  practicable  we  can  generally  imitate  the 
former  sufficiently  well  to  produce  much  the  same  effects  upon  the 
patient.  We  can  prescribe  the  quantity  and  kind  of  food  and  fre- 
quency of  taking  it,  the  character  and  amount  of  outdoor  exercise, 
according  to  her  circumstances  and  ability  to  afford  it.  This  plan  is 
generally  practicable  even  with  people  in  moderate  circumstances,  if 
the  physician  will  properly  study  the  matter.  (See  General  Treat- 
ment of  Uterine  Disease,  from  pages  397  to  415.) 

Another  probably  not  less  essential  part  of  the  treatment  is  the 
correction  as  near  as  possible  of  every  abnormal  condition  found  in 
all  the  associate  organs,  the  uterus,  vagina,  tubes,  etc.  With  the  ex- 
ception of  displacements,  the  remedies  addressed  to  the  diseases  of  all 
the  pelvic  organs  affect  the  ovaries  as  well.  For  chronic  inflamma- 
tion of  the  uterus  and  broad  ligaments,  we  prescribe  the  hot-water 
douches,  sitz-baths,  glycerin  tampons,  iodine  counter-irritation,  etc. 
And  these  used  perseveringly  are  precisely  those  from  which  we  would 
expect  the  most  good  in  cases  of  chronic  ovaritis. 


CHAPTER    XLIL 

AFFECTIONS  OF  THE  OVAEIES  (Continued)— OVA RIA'!^  TUMORS. 

Anatomy. 

In  the  ovarian  tumors  proper,  we  may  trace  three  coats  or  layers 
of  tissue  forming  their  walls.  The  external  is  the  serous  or  perito- 
neal. It  is  shining  and  smooth  as  this  membrane  is  elsewhere,  and 
seldom  changed  in  any  way,  except  it  may  be  thickened  and  hyper- 
trophied.  It  can  be  traced  into  the  peritoneal  covering  of  the  viscera 
and  abdominal  parietes,  and  consequently  needs  no  elaborate  descrip- 
tion. The  internal  coat  or  lining  membrane  is  doubtless  the  mem- 
brana  granulosa  of  the  ovisac,  very  much  hypertrophied.  When 
small,  something  like  epithelium  seems  to  be  its  entire  composition. 
As  it  grows  and  develops,  the  epithelial  arrangement  is  less  perfect, 
until,  when  very  large,  we  can  observe  it  only  in  patches.  In  many 
cases  when  thus  large,  this  membrane  has  a  smooth,  lustrous  appear- 
ance, but  in  others  it  is  more  or  less  thickly  studded  with  granular 
projections,  varying  from  almost  imperceptible  minuteness  to  the  size 
of  peas,  or  even  larger.  Regarding  the  main  sac  as  an  hypertrophied 
ovisac,  I  think  these  little  granular  sacs  (for  they  prove  to  be  sacs 
upon  examination)  are  also  of  the  same  nature  and  are  the  origin  of 
the  numerous  endogenous  or  supplementary  growths  which  constitute 
one  of  the  polycystic  varieties. 

The  middle  coat  is  made  up  from  the  stroma  of  the  ovary.  Its 
strength  depends  upon  quite  a  considerable  amount  of  fibres,  which 
enter  into  its  composition.  As  the  tumor  develops,  these  fibres  are 
enlarged,  and  apparently,  if  not  really,  increased  in  numbers,  until 
they  constitute  the  most  of  the  thickness  of  the  walls,  and  in  some 
parts  make  quite  a  thick,  dense,  and  tough  tissue.  These  qualities 
are  greater  in  old  large  sacs  than  in  the  smaller  and  younger  ones. 
At  the  pedicle,  and  for  some  distance  up  the  sides,  they  are  greater 
than  in  other  portions,  being  in  these  parts  sometimes  a  quarter  of 
an  inch  thick,  while  at  the  fundus  or  distal  portion  they  may  be 
thin  and  fragile.  The  whole  of  this  coat  may  be  very  tough  and 
thick,  so  as  to  resist  great  force,  or  it  may  be  thin  throughout,  so  as 
to  be  easily  ruptured  at  almost  any  point.  Entangled  in  the  meshes 
of  these  fibres  may  be  discovered,  in  many  cases,  the  minute  micro- 
scopic points  so  numerously  scattered  through  the  substance  of  the 
ovaria.  These  points  are  believed  to  be  the  origin  of  the  germinal 
spot  in  the  ovum  by  some  physiologists,  and  around  which  are  de- 


696  OVAEIAN    TUMORS. 

veloped  the  ovum,  and  progressively  the  whole  ovisacs  and  their  con- 
tents; and  I  believe  that  their  presence  in  the  walls  of  the  tumors, 
over  much,  if  not  the  whole,  of  their  extent,  accounts  for  the  devel- 
opment of  the  minute  granular  internal  projections  above  described. 
In  a  tumor  recently  removed  from  the  body,  by  holding  it  up  to  the 
light,  we  may  not  unfrequently  discover  the  peculiar  huffy  tinge  seen 
in  the  stroma.  The  vessels  are  situated  in  this  coat.  They  are 
numerous  and  some  of  them  large,  so  large  that  great  care  is  necessary 
to  prevent  them  from  bleeding  when  the  peduncle  is  divided.  They 
are  developed,  it  is  hardly  necessary  to  say,  to  this  great  size  from 
the  minute  twigs  which  penetrate  the  substance  of  the  ovary. 

The  shape  of  ovarian  tumors  may  vary  much.  They  may  be  regu- 
larly globular,  polyglobular,  angular,  or  irregular  in  almost  every 
way.  When  small,  the  ovary  may  be  seen  as  constituting  a  consider- 
able portion  of  the  tumor.  When  large,  the  ovary  may  be  almost- 
lost  in  the  walls,  or  observed  as  a  mere  tubercle  sticking  to  or  im- 
bedded in  its  side.  Generally  but  one  ovary  is  the  seat  of  disease, 
but  in  rare  instances  both  are  affected.  Ovarian  tumors  divide  them- 
selves anatomically  into  monocystic  and  polycystic, — the  one  having 
a  single  cystic  cavity,  the  other  several.  The  polycystic  variety  is 
formed  by  the  development  of  several  cysts  adjoining  or  by  the  side 
of  each  other,  and  independently  attached  to  or  springing  from  each 
other  on  the  external  surface,  or  within  the  cavity  of  one  large  one. 
The  instances  of  poly  cysts  growing  by  the  side  of  each  other,  and 
being  independently  attached,  resembles  at  first  the  monocysts.  At  an 
early  stage  of  development  they  may  stand  free  of  contact  one  with  the 
other,  but  as  they  grow  in  size,  in  consequence  of  the  small  surface 
of  the  ovary  to  which  they  are  attached,  they  crowd  together,  so  that 
it  is  not  always  easy  to  say  whether  they  were  not  developed  from 
each  other.  The  cysts  from  which  smaller  ones  grow  are  called  pro- 
liferous. They  are  doubtless  single  for  some  time  in  their  early 
development,  but  carrying  up,  as  they  increase  in  size,  the  proper 
substance  of  the  ovary,  with  its  rudimentary  ovisacs,  after  awhile  the 
inner  or  outer  surface  is  bulged  by  the  maturity  of  these  last,  which, 
if  they  do  not  dehisce  and  allow  the  escape  of  the  ovum,  grow  into  a 
subordinate  tumor.  This  process  is  separate  until  there  is  a  glomera- 
tion  of  cysts  to  quite  a  number,  from  four  to  fifty,  of  various  sizes, 
from  the  size  of  a  man's  head  down  to  that  of  a  pin's  head.  Small 
ones  may  be  so  numerous  as  to  stud  a  large  part  of  the  inner  surface 
with  granulated  elevations.  This  is  the  most  frequent  variety  met 
with  in  practice.  When  the  minor  sacs  grow  from  the  inner  surface 
of  a  large  cyst,  the  tumor  is  denominated  oligocystic. 

There  is  a  great  difference  in  the  sensible  qualities  of  the  contents 
of  the  cysts  in  different  cases,  and  of  the  different  cysts  in  the  same 
case.     In  some  it  is  very  thin,  in  others  very  thick  and  tenacious, 


NATURE    AND    ANATOMY.  697 

while  the  color  shades  from  black,  inky,  to  limpid  clearness.  Not 
unfrequentl}^  large  fibroid  growths  are  observed  in  the  ovary  at  the 
base  of  a  single  or  multiple  cystic  tumor.  These  solid  fibroid  or 
fibrous  growths  may  be  simple  or  benign  in  their  nature,  or  malig- 
nant. This  complication  of  ovarian  dropsy  I  think  is  more  frequent 
in  persons  advanced  in  years — over  forty — than  in  younger  ones.  The 
contained  fluid  of  the  polycystic  tumor  is  ordinarily  highly  albumi- 
nous, of  high  specific  gravity,  tenacious,  and  more  or  less  colored. 
The  fluid  is  sometimes  so  thick  as  not  to  flow  through  a  canula. 
Occasionally  we  meet  with  sacs  which  contain  blood  ;  more  frequentl}'' 
serum  colored  with  blood ;  in  others  pus,  or  serum  and  pus.  From 
one  tumor  of  several  cysts,  I  drew  pus  from  one  cyst;  dark  coffee- 
grounds  sanguineo-serous  fluid  from  another ;  a  beautiful  straw  color 
from  another  ;  and  lastly,  from  another,  fluid  of  a  delicate  azure  tint. 
After  tapping,  more  or  less  alteration  is  observed  in  the  fluid,  each 
operation  withdrawing  fluid  affected  by  chemical  or  pathological  con- 
ditions. In  the  former,  putridity  or  acridity ;  in  the  latter,  the  puru- 
lent productions  of  inflammation. 

There  are  some  chemical  and  microscopic  resemblances  in  the  fluid 
from  almost  all  varieties  of  ovarian  tumor.  Albumen  in  some  of  its 
forms  is  always  present.  In  some  specimens  of  fluid,  strong  acids, 
or  heat,  cause  it  to  assume  a  solid  form,  coagulating  and  adhering 
like  the  white  of  an  egg  when  cooked  in  boiling  water ;  in  others  a 
small  precipitate  is  all  that  is  observed.  Between  these  extremes  all 
shades  of  diff"erence  exist.  The  reaction  is  alkaline.  Mr.  Nunn 
says  that,  "  As  the  results  of  many  examinations  (microscopic)  of 
difierent  specimens  of  ovarian  fluid,  the  most  constant  characteristic 
of  such  fluid  is  its  containing,  in  greater  or  less  abundance,  cells 
gorged  with  granules ;  and,  in  addition,  circumambient  granules, 
having  the  same  measurement,  encompassed  by  the  cell.  The  size  of 
the  gorged  cells  and  included  granules  varies  greatly,  even  in  fluid  from 
different  cysts  in  the  same  ovary."  This  description  of  fluid  could, 
with  certainty,  remain  good  of  the  first  evacuation  only,  as  pus  and 
blood-globules  are  not  unfrequently  found  in  subsequent  evacuations. 

The  fibrous  or  solid  variety  of  ovarian  tumors  is  occasionally  met 
with.  Dr.  Bogue,  about  ten  years  since,  removed  a  solid  tumor  of  the 
ovary  at  the  Cook  County  Hospital,  which  weighed  forty  ounces.  It 
was  very  dense  and  fibrous  in  structure. 

The  very  remarkable  tumor  called  dermoid  is  so  seldom  met  with 
and  so  little  is  said  of  them  in  the  textbooks  that  I  feel  justified  in 
copying  somewhat  at  length  from  my  article  on  dermoid  ovarian 
tumors,  in  the  third  volume  of  the  Transactions  of  the  American  Gyne- 
cological Society : 

Case  I. — In  the  spring  of  1874,  the  patient,  a  girl,  eighteen  years  of 
age,  noticed  an  enlargement  in  the  left  iliac  region,  which  finally  be- 


698  OVARIAN   TUMORS. 

came  so  great  that  in  October,  1875,  she  was  distressed  from  the  dis- 
tension. At  this  time  she  was  tapped  and  about  ten  quarts  of  fluid 
evacuated.  The  fluid  was  somewhat  tenacious,  of  a  clear,  slightly 
bluish  tinge,  and  contained  the  ovarian  cell.  The  outline  of  the  tumor 
could  be  traced  quite  easily  after  the  tapping.  It  occupied  the  whole 
width  of  the  abdomen  between  the  two  iliac  fossse  and  extended 
upwards  to  within  two  inches  of  the  umbilicus.  It  was  globular  and 
of  soft  consistence. 

After  this  operation  the  tumor  filled  quite  rapidly,  and  on  January 
1st,  1876,  the  patient  was  as  large  as  before  the  fluid  was  evacuated. 

On  January  4th,  ovariotomy  was  performed.  There  were  no  adhe- 
sions or  other  source  of  embarrassment  to  the  removal  of  the  tumor, 
and  the  patient  made  a  good  recovery. 

The  sac  was  thin  but  firm,  and  presented  the  peculiarly  pearly 
aspect  of  the  ordinary  ovarian  tumor.  When  the  large  Wells's  trocar 
was  introduced  nothing  but  serum  flowed  through  the  tube.  Upon 
being  opened  the  tumor  was  found  to  contain  about  half  a  pound  of 
sebaceous  fat.  The  inner  surface  was  smooth,  except  a  small  part 
about  the  size  of  the  palm  of  the  hand  situated  at  the  bottom  near 
the  pedicle.  Here  the  surface  was  depressed  at  least  an  inch  below 
the  level  of  the  inner  surface,  and,  although  not  sacculated,  had  a 
well-defined  and  pursy  margin.  The  bottom  of  this  depression  was 
covered  with  dermic  tissue,  and  upon  it  grew  an  abundant  crop  of 
dark-brown  hair  about  an  inch  long.  It  was  very  fine,  and  firmly 
attached.  Doubtless  the  dermic  patch  was  the  source  of  the  fatty 
material  found  floating  in  the  cyst  which,  on  cooling,  assumed  the 
consistence  and  appearance  of  yellow  butter.  Upon  closer  inspection 
of  the  smooth  lining  of  the  larger  part  of  the  tumor  it  was  found  to 
be  studded  with  very  minute  papillae,  such  as  we  sometimes  see  in 
oligocystic  ovarian  tumors. 

This  specimen  I  regard  as  not  a  true  dermoid  cyst,  but  as  a  com- 
plex dermo-ovarian  tumor,  a  tumor  originating  in  a  Graaffian  follicle 
in  which  a  tegumentary  element  had  been  inclosed.  It  contained  no 
bone  or  teeth  such  as  are  often  found  in  the  true  dermoid  tumor,  but 
did  contain  undoubted  colloid  fluid,  diluted  with  the  watery  product 
from  the  sweat  glands  of  the  dermic  membrane  upon  which  the  hair 
was  implanted. 

Case  II. — Mrs.  P.,  aged  forty-three  years,  the  mother  of  one  child, 
eighteen  years  old,  became  aware  of  an  enlargement  of  the  abdomen 
about  ten  months  before  the  operation,  which  was  performed  June 
28th,  1876.  During  that  time  she  grew  to  the  size  of  pregnancy  at  full 
term.  The  tumor  filled  the  abdominal  cavity  and  extended  to  the 
ensiform  cartilage.  There  was  no  difficulty  in  deciding  that  it  was 
monocystic  and  contained  a  thin  fluid.  The  operation  was  not 
attended  Avith  difficulty  in  any  respect.     There  were  no  adhesions, 


NATURE    AND    ANATOMY.  699 

and  after  evacuation  the  sac  passed  through  an  incision  only  three 
inches  long.  The  patient  experienced  considerahle  depression  from 
the  shock  of  the  operation.  This,  however,  lasted  but  a  few  hours,  no 
other  disagreeable  symptoms  supervening.  The  recovery  was  rapid. 
The  care  of  the  case  after  the  operation  was  undertaken  by  Dr.  S.  W. 
Green,  of  Marengo,  Illinois. 

The  cyst  was  single,  thin,  and  uniform,  except  at  the  part  opposite 
the  pedicle,  where  its  wall  was  about  half  an  inch  thick  and  contained 
a  thick  layer  of  adipose  tissue.  Upon  the  inner  surface  of  this  part 
was  a  thick  tegumentary  covering,  upon  which  w^as  implanted  a  dense 
mass  of  blonde  hair,  matted  together,  and  nearly  the  size  of  an  orange., 
The  whole  of  the  inner  surface  of  the  sac  elsewhere  was  smooth  and 
of  a  buff  color.  The  external  surface  was  of  a  pearly  hue  and  smooth. 
There  was  no  evidence  of  bony  or  dental  tissue.  The  fluid  was  quite 
thin,  of  a  slightly  blue  tinge,  and  floating  in  it  in  considerable  masses 
were  ten  to  twelve  ounces  of  yellow  sebaceous  fat.  The  hairs,  when 
straightened  out,  measured  from  six  to  fifteen  inches  in  length. 

This  example  I  regard  as  a  simple  dermoid  cyst  of  the  ovary,  there 
being  no  sign  of  follicular  papillee  upon  the  inner  surface,  and  the 
fluid  not  being  in  the  least  tenacious  or  colloid  in  appearance ;  more- 
over, I  was  unable  to  find  in  it  the  ovarian  cell.  I  think  the  fluid  was 
the  product  of  the  sweat  glands  in  the  dermic  structure  at  the  bottom 
of  the  cyst. 

Case  III. — Mrs.  P.,  a  small  Jewess,  thirty-one  years  of  age,  the 
mother  of  four  children,  the  youngest  being  three  years  old,  noticed 
about  nine  months  before  the  operation — which  was  performed  April 
7th,  1875 — that  the  abdomen  had  commenced  enlarging.  The  tumor 
was  found  to  be  monocystic  and  so  completely  filling  the  abdomen  that 
the  patient  had  great  inconvenience  from  distension. 

The  removal  of  this  tumor,  which  originated  in  the  left  ovary,  was 
easy,  as  no  adhesion  or  other  obstacles  were  encountered.  The  patient 
recovered  without  experiencing  any  untoward  symptoms. 

The  tumor  was  composed  of  a  single  cyst,  of  which  the  wall  was 
thin  over  about  three-fourths  of  its  circumference  and  easily  ruptured. 
At  the  bottom  or  pedicular  portion,  involving  about  one-fourth  of  the 
inner  surface,  was  a  dense  mass  of  areolar  tissue  literally  filled  with 
pieces  of  bone.  The  greater  number  of  these  pieces  were  cylindrical, 
from  half  an  inch  to  two  inches  in  length,  and  varying  from  an  eighth 
to  a  quarter  of  an  inch  in  thickness.  They  seemed  to  be  imbedded  in 
loose  cellular  tissue,  were  not  attached  to  each  other,  and  were  easily 
removed  by  the  finger.  Other  masses  of  bone,  made  up  of  alveoli, 
were  not  unlike  the  maxillary  processes,  and  varied  in  length  from 
one  to  two  inches,  and  in  width  from  one-third  to  one-half  inch.  They 
resembled  honeycomb,  and  were  quite  firmly  attached  to  the  cyst  wail. 
The  microscope  showed  their  structure  to  be  that  of  true  bony  tissue. 


700  OVARIAN   TUMORS. 

This  mass  was  covered  by  a  tegumentary  membrane  to  which  were 
attached  more  than  a  hundred  imperfect  incisor  teeth,  distributed  over 
the  whole  surface,  their  adhesions  being  so  slight  that  they  could 
easily  be  scraped  from  the  surface  with  the  finger.  These  dental  bodies 
were  all  about  the  same  size,  and  consisted  merely  of  the  crown,  but 
the  enamel  and  dentine  seemed  perfect.  They  had  no  connection 
whatever  with  the  bony  tissue.  Interspersed  among  these  teeth  was  a 
dense  crop  of  blonde  hair,  averaging  an  inch  in  length. 

The  fluid,  of  which  there  was  about  10  quarts,  sp.  gr.  1008,  was 
clear,  with  a  slight  bluish  tinge,  and  entirely  devoid  of  tenacity  or 
other  colloid  properties.  I  believed  it  to  be  perspiratory  serum.  There 
were  also  several  ounces  of  yellow  sebaceous  fatty  matter  within  the 
cyst. 

I  should  class  this  tumor  among  the  true  dermoid  cysts  of  the  ovary, 
and  believe  that  it  possessed  none  of  the  properties  of  the  ordinary 
ovarian  tumor.  Its  structure  was  much  more  complex  than  that  of 
the  two  preceding  tumors,  but  much  less  so  than  that  to  which  I  shall 
now  call  attention. 

Case  IV. — Mrs.  B.,  thirty-five  years  of  age,  the  mother  of  four  chil- 
dren, the  last  twenty  months  old,  first  noticed  a  tumor  in  the  right 
iliac  region  nine  years  before  operation.  It  was  then  about  the  size  of 
her  fist.  It  had  grown  steadily  but  slowly  until  June  19th,  1878,  when 
it  was  extirpated.  The  growth  did  not  seem  to  be  influenced  by 
pregnancy.  She  had  borne  three  children  from  the  time  when  the 
tumor  was  discovered  to  the  time  of  its  removal.  Her  health  had  been 
feeble  for  several  years,  but  from  the  birth  of  her  last  child  she  had 
been  confined  to  bed  half  of  each  day,  and,  for  several  weeks,  all  the 
time.  The  main  inconvenience  was  from  the  weight  and  mobility  of 
the  tumor.  When  she  Avas  in  the  erect  posture  it  caused  dysuria  and 
rectal  tenesmus  ;  when  lying  on  either  side  it  pressed  upon  the  subja- 
cent viscera  and  also  dragged  upon  the  upper  side ;  the  only  com- 
fortable position  was  the  dorsal.  The  pulse  and  temperature  were 
decidedly  and  continuously  above  the  normal  standard.  She  was 
sleepless,  had  a  very  poor  appetite,  and  was  rapidly  becoming  ema- 
ciated. The  above  very  brief  history  was  given  me  by  the  attending 
physician.  Dr.  J.  H.  Low,  of  Brimfield,  Illinois. 

The  appearance  of  the  abdomen  was  very  singular.  It  was  con- 
siderably distended  ;  from  its  centre,  including  in  fiict  the  whole 
umbilical  region,  arose  a  round  projection  exactly  resembling  a  ven- 
tral hernia,  the  umbilicus  occupying  its  apex.  It  measured  five 
inches  in  diameter,  and  protruded  three  and  a  half  inches  above  the 
common  level.  It  Avas  fluctuating  and  dull  upon  percussion.  On 
each  side  I  could  easily  distinguish  two  other,  apparently  larger,  cysts 
not  projecting  above  the  surface.  Percussion  over  these  elicited  no 
resonance,  but  it  was  easy  to  detect  fluctuation.     The  tumor  could  be 


XATUEE    AND    ANATOMY.  701 

moved  pretty  freely  in  all  directions  without  traction  upon  any  part 
of  the  abdominal  walls.  By  external  and  internal  manipulation  I 
could  trace  the  attachment  of  the  mass  to  the  right  side  of  the  pelvis 
and  assure  myself  that  it  was  not  of  uterine  origin.  It  was  clear  that 
I  had  to  deal  with  a  tumor  made  up,  principally  at  least,  of  three 
cysts,  and  quite  certainly  originating  in  the  right  ovary,  but  it  pre- 
sented so  many  unusual  symptoms  and  appearances,  that  further 
diagnostic  measures  were  necessary  before  I  would  venture  to  remove 
it.  After  making  preparations  for  its  extirpation,  the  patient  being 
fully  etherized,  I  introduced  a  small  trocar  into  the  prominent  cyst. 
A  little  sebaceous  fat  flowed  through  the  canula,  and  at  once  made 
the  diagnosis  complete.  The  usual  small  incision  exposed  the  pearly 
cyst  and  allowed  me  to  evacuate  the  prominent  sac  of  one  quart  of 
thin,  yellow  fat.  The  other  two  cysts  were  drawn  to  the  opening, 
and  their  contents,  of  a  similar  character,  evacuated.  By  this  time 
the  rubber  blanket  was  smeared  with  a  sticky  grease,  the  instruments 
had  become  slippery,  and  my  fingers  were  encumbered  with  a  mass 
of  fat  which  had  to  be  removed  before  I  could  proceed  with  the 
operation.  The  cysts  were  drawn  through  an  incision  about  three 
inches  long,  and  a  short,  slender  pedicle,  consisting  of  the  right 
ovarian  ligament,  part  of  the  broad  ligament,  and  Fallopian  tube, 
was  brought  up  into  the  wounds,  ligated,  cut,  and  dropped  into  the 
pelvic  cavity.  The  left  ovary  was  healthy.  As  nothing  had  been 
allowed  to  pass  into  the  peritoneal  cavity  the  incision  was  then  closed. 
It  will  have  been  seen  by  this  description  that  no  adhesions  or  other 
impediment  hindered  or  complicated  the  operation.  It  was  remark- 
able how  extremely  greasy  everything  employed  in  the  operation 
became,  and  I  had  more  trouble  in  cleansing  the  instruments  from 
the  grease  than  is  usually  experienced  in  getting  rid  of  the  blood  and 
mucoid  fluid  of  the  common  ovarian  tumor.  The  patient  had  no 
untoward  symptoms,  seeming  to  me  more  like  one  recovering  from 
the  exhaustion  and  irritation  in  which  I  had  found  her  than  from  the 
hazardous  operation  for  the  removal  of  an  ovarian  tumor. 

Before  describing  the  tumor  I  wish  to  call  attention  to  the  fact 
that  there  was  no  serum  evacuated  during  the  operation  ;  no  fluid  but 
the  soft  fat  was  observed.  The  tumor  proved  to  be  a  remarkable 
specimen  of  the  true  dermoid  variety,  nothing  in  its  contents  seem- 
ing to  be  of  ovarian  origin.  The  cyst  wall  was  thin,  but  of  firm 
structure,  and  divided  into  three  compartments  of  about  equal 
dimensions.  The  septa  were  complete,  and  of  the  same  consistence 
and  density  as  the  external  wall.  At  the  base  of  the  tumor  the  sac 
was  more  dense  and  firm  than  elsewhere.  The  peculiar  formations 
contained  in  each  cyst  were  so  nearl}'-  alike  that  a  description  of  the 
contents  of  one  will  suffice  for  each  of  the  other  two. 

On  opening  the  cysts  each  was  found  to  contain  a  mass  of  matted 


702  OVARIAN   TUMORS. 

hair,  the  size  of  a  lemon,  thoroughly  supplied  with  the  same  fatty 
substance  that  had  been  evacuated  from  the  tumor.  One  of  these 
rolls  of  hair  was  red,  another  blonde,  and  the  other  gray.  The  pa- 
tient's hair  was  dark  brown.  Some  of  this  hair  was  twenty  inches 
long,  and  it  was  all  attached  to  tegumentary  substance  closely  re- 
sembling the  scalp.  The  dermic  structure,  which  was  about  four 
inches  across,  rested  upon  a  very  uneven  layer  of  adipose  tissue  an 
inch  thick.  By  the  side  of  the  dermic  patch,  and  not  covered  by  it, 
was  a  loose  layer  of  areolar  tissue,  an  inch  and  a  half  thick,  contain- 
ing bones  in  a  great  variety  of  shapes, — scales,  round  bones  an  inch 
or  more  in  length,  alveolar  nodules,  etc.  Upon  the  surface  of  this 
part  of  the  tumor  in  each  cyst  was  a  half-arch  of  teeth  the  shape  of 
one-half  the  superior  maxilla.  In  one  cyst  the  crowns  of  the  teeth 
projected  aboA^e  the  surface,  while  in  the  other  two  they  were  thinly 
covered  by  tissue  so  soft  that  it  could  be  pinched  off  by  the  thumb 
and  finger.  The  teeth  were  not  attached  to  the  subjacent  bones,  but 
were  simply  imbedded  in  the  loose  mass.  The  teeth  in  each  segment 
very  perfectly  represented,  respectively,  an  incisor  and  three  molars, 
each  having  three  well-marked  fangs.  One  of  the  molars  in  each  row 
strongly  resembled  the  wisdom  tooth.  The  perfection  of  their  forma- 
tion will  be  recognized  in  the  specimens  which  I  submit  for  your 
examination.  The  crown  with  the  enamel  and  eminences,  the  main 
body,  and  roots  are  as  distinctly  marked  as  if  they  had  been  removed 
from  alveolar  cavities. 

Before  leaving  the  description  of  the  tumors  and  their  removal,  I 
would  call  your  attention  to  the  great  simplicity  of  the  operation  and 
the  fortunate  recovery  of  all  the  patients,  no  adhesions  or  other  coni- 
plications  having  existed. 

Now  what  is  a  dermoid  tumor?  This  name  is  given  to  a  c^'st 
formed  anywhere  in  the  body,  the  internal  or  lining  membrane  of 
which  is  in  ]3art  or  wholly  tegumentary  in  structure.  As  now  un- 
derstood, the  presence  of  this  condition  alone  would  justify  this 
nomenclature.  The  formation  seems  to  be  no  less  an  error  of  struct- 
ure than  location.  Lebert,  Paget,  Virchow,  and  most  other  modern 
pathologists  agree  that  the  dermic  tissue  thus  located  is  essentially  the 
same  in  structure  as  true  skin.  The  products  are  all  the  same,  hair, 
sebaceous  fat,  and  perspiratory  fluid.  In  many  of  these  tumors  we 
find  subcutaneous  adipose  tissue  very  perfectly  formed.  Less  con- 
stantly, teeth,  bone,  muscular,  nervous,  and  even  brain  tissues.  These 
latter,  excejit  the  teeth,  in  some  instances,  are  found  either  beneath 
the  dermic  membrane  or  beneath  the  portion  of  the  internal  surface 
not  lined  by  this  cutaneous  substance. 

My  observation  shows  that  the  dermic  tissue  and  its  i^roducts  char- 
acterize one  variety  of  these  formations,  as  in  Cases  II  and  III. 
These  constituents  are  sometimes  found  alone,  and  may  then  be  re- 


NATURE    AXD    ANATOMY.  703 

garded  as  indicative  of  a  more  simple  formation,  -while  the  addition 
of  bone,  muscle,  etc.,  constitute  a  more  complex  order  of  tumor  rep- 
resented by  Case  IV.  The  bone  and  muscle,  however,  are  never 
found  in  a  tumor  of  this  kind  without  the  dermic  membrane,  its 
essential  glands,  and  their  products.  Another  thing  quite  apparent 
is  that  the  skin  and  its  appendages  are  not  only  constantly  present, 
but  comparatively  perfect  in  their  organization.  The  teeth,  which 
are  very  closely  associated  in  embryonic  metamorphosis  with  the  for- 
mation of  the  skin,  stand  next ;  many  being  quite  perfect  in  their 
structure.  The  bony,  muscular,  and  nervous  structures,  although 
complete  in  their  texture  and  formation,  are  never  developed  into 
complete  organs.  I  am  aware  that  cases  have  been  recorded, — as,  for 
instance,  by  Blumbach  and  Rokitansky, — that  would  seem  to  be  at 
variance  with  this  assertion  ;  but  the  bones  in  these  cases  lacked  the 
completeness  in  structure  necessary  to  entitle  them  to  be  classified 
with  any  of  the  bones  in  the  human  skeleton.  When  some  or  all  of 
these  structures,  together  with  the  products  of  the  dermic  tissue,  con- 
stitute all  the  contents  of  the  cyst,  the  specimen  should  be  regarded 
as  a  simple  dermic  tumor,  even  when  formed  in  the  ovary,  the  fact 
of  its  having  found  a  lodgment  in  that  organ  being  an  accidental 
rather  than  a  necessary  condition.  When,  however,  it  exists  in  the 
ovary,  and  with  these  substances  there  is  found  the  colloid  or  mucoid 
fluid  characteristic  of  the  ordinary  ovarian  tumor,  it  is  not  merely  a 
dermoid,  but  an  ovarian  dermoid  tumor.  It  is  a  mixed  neoplasm,  a 
morbid  development  of  the  ovarian  follicles  in  connection  with  the 
congenital  dermoid.  In  my  first  case  this  was  the  character  of  the 
tumor ;  and  instances  of  this  kind  are  recorded  in  the  well-known 
books  of  Drs.  Atlee,  Peaslee,  and  Mr.  Wells.  The  first  variety,  then, 
although  often  found  in  the  ovary,  differs  in  no  essential  particular 
from  those  found  elsewhere,  except  in  magnitude,  and  perhaps  greater 
perfection  of  organized  development.  Possibly  this  last  difference 
does  not  exist. 

When  found  in  the  ovar}^,  either  in  the  single  or  mixed  form,  the 
investing  membrane  seems  to  be  the  same  in  appearance  and  structure 
as  in  ordinary  ovarian  tumors  ;  and,  when  first  exposed,  it  is  often  not 
easy,  if  at  all  possible,  to  distinguish  between  them  until  some  of  their 
contents  are  evacuated. 

To  the  more  fluid  products  of  the  first  variety  of  simple  dermoid 
cysts,  especially  the  secretion  from  the  dermic  tissue,  such  as  the  serous 
or  perspiratory  fluid,  we  must  attribute  the  difference  in  the  size  of 
this  form  of  tumor.  The  sebaceous  product  is  also  sometimes  quite 
bulky,  as  seen  in  Case  IV ;  but  when  the  sudoriparous  glands  are 
numerous  and  active,  the  amount  of  watery  fluid  is  sometimes  enor- 
mous, and  consequently  the  tumor  grows  to  be  very  large,  as  may  be 
specially  noted  in  the  second  case.     In  such  instances,  from  causes 


704  OVAEIAN    TUMORS 

which  are  not  appreciated,  the  sudoriparous  glands  seem  suddenly  to 
acquire  great  functional  activity,  and  by  pouring  into  the  tumor  a 
large  supply  of  fluid  make  it  grow  with  great  rapidity. 

As  there  was  no  appreciable  amount  of  serum  in  Case  IV,  the  sac 
being  filled  with  the  sebaceous  matter,  it  is  easily  understood  why  the 
tumor  was  a  long  time  in  attaining  the  dimensions  it  finally  acquired. 
The  solid  contents  of  these  tumors,  as  far  as  I  can  learn,  do  not  grow 
to  a  sufficient  extent  to  give  them  any  great  bulk,  and  consequently, 
when  situated  in  the  ovary,  such  a  tumor,  apart  from  its  fluid  contents, 
would  hardly  require  extirpation. 

The  compound  variety,  or  ovarian  dermoid,  would  be  likely  to  grow 
to  a  great  size  in  consequence  of  the  accumulation  of  the  colloid  secre- 
tion, just  as  they  would  if  the  dermoid  element  did  not  exist.  By 
consulting  the  literature  of  the  subject,  I  am  led  to  the  conclusion  that 
the  dermoid  and  colloid  contents  of  these  compound  cysts  are  usually 
contained  in  different  co'mpartments  of  the  tumor.  This  was  notably 
the  case  in  some  of  Mr.  Wells's  specimens. 

There  are  one  or  two'  facts  which  may  have  some  bearing  upon  the 
production  and  developm<ent  o-f  these  tumors  r  The  dermic  membrane 
is  always  superficial  with  reference  to  the  inner  surface  of  the  tumor  ; 
the  hair  always,  and  the  teeth  often,  grow  from  its  surface ;  while  the 
bone  and  other  tissues  are  situated  below  it,  but  not  always  imme- 
diately under  it.  In  my  fourth  specimen  the  bone  was  imbedded  in 
a  mass  of  cellular  substance  by  the  side  of  the  cutaneous  layer,  giving 
me  the  idea  that  it  belonged  to  a  blastodermic  formation  deeper  than 
the  tegumentary  portion  of  the  surface. 

The  question  here  naturally  presents  itself:  Whether  the  simpler 
forms  of  these  dermoid  cysts,  in  which  the  dermoid  structure,  with 
hair,  fat,  and  serum  are  found  without  any  of  the  deeper  tissues,  are 
tumors  in  the  process  of  development  into  the  more  complicated  va- 
riety ?  I  think  not,  and  believe  that  each  tumor  receives  during  its 
embryonic  state  all  the  elements  of  formation  it  is  capable  of  producing  ; 
that  the  trophic  qualities  imparted  to  it  then  definitely  limit  its  possi- 
bilities. If  so,  it  necessarily  follows  that  the  tumor,  containing  all  the 
variety  of  structure  ever  found  in  them,  should  manifest  these  qualities 
and  structures  without  gradation  of  growth,  and  possess  from  the  be- 
ginning the  complex  qualities  found  in  advanced  periods  of  life. 

Theories  of  their  Origin. 

The  theories  de^dsed  tO'  explain  the  origin  and  development  of 
ovarian  dermoid  tumors  represent,  with  some  degree  of  exactness,  the 
physiology  of  the  times  in  which  they  originated.  In  the  earlier  ages 
of  medicine,  physiology  was  the  creature  of  imagination.  Definite 
knowledge  of  the  internal  organs  was  wholly  wanting ;   if  possible, 


NATURE   AND   ANATOMY.  705 

even  less  was  known  of  their  functions.  Pathology  also  rested  upon 
the  same  unsubstantial  basis.  As  a  consequence,  the  theories  of  the 
origin  and  development  of  these  curious  growths  were  all  vague  and 
imaginary.  In  the  latest  and  most  plausible  explanation  yet  offered, 
we  have  the  results  of  the  present  highly  cultivated  science  of  physi- 
ology ;  and  if  not  absolutely  true,  there  can  be  fewer  rational  and 
scientific  objections  opposed  to  it  than  to  any  of  its  predecessors. 

It  is  not  my  present  purpose  to  do  more  than  give  a  very  cursory 
view  of  some  of  the  most  prominent  theories  which  have  at  different 
ages  been  presented  to,  and  accepted  by,  a  large  portion  of  the  pro- 
fession at  the  time  they  were  promulgated.  I  will  classify  the  theo- 
ries under  three  divisions :  I.  Those  originating  in  the  imagination 
alone  without  any  scientific  foundation.  II.  Those  which  have  for 
their  basis  the  superstitions  of  the  times  in  which  they  originated, 
and  of  the  people  by  whom  they  were  entertained.  III.  The  scien- 
tific theories. 

I.  The  most  ancient  of  the  imaginative  theories  is,  I  believe,  attrib- 
uted to  Aristotle.  It  taught  that  the  dermoid  products  of  these  tumors 
— as  the  hair,  teeth,  etc. — had  been  swallowed  and  transmitted  in  some 
unknown  manner  to  the  localities  occupied  by  them.  This  idea  is  a 
good  match  for  many  of  the  ingenious  vagaries  of  that  wise  man. 

Belief  in  virginal  pregnancy  supplied  the  basis  of  another  and  ex- 
tensively prevalent  theory.  It  assumed  several  forms.  One  was  the 
abstract  possibility  of  a  virgin  becoming  impregnated  without  sexual 
intercourse,  or  true  parthogenesis.  Another  was  that  the  ovaries  pos- 
sessed properties  that  enabled  them  to  produce,  to  a  limited  extent, 
the  organized  bodies  resembling  the  parts  of  a  foetus ;  or,  again,  that 
certain  unsatisfied  sexual  longings  of  an  isolated  woman  might  stimu- 
late the  ovaries  to  imperfect  generative  processes. 

Still  another  was  that  certain  individuals  possessed  a  sort  of  ovario- 
cystic  diathesis  which  took  this  direction. 

It  is  easy  to  see  that  these  vagaries — for  they  ought  not  to  be  dig- 
nified by  the  term  theories — had  no  physiological  basis  and  could  be 
the  products  of  imagination  alone. 

II.  The  superstition  of  mediaeval  times  gave  rise  to  the  theory 
that  these  tumors  were  visitations  of  Providence  upon  the  subjects  of 
them  on  account  of  particular  sins.  The  infliction  of  this  punishment 
upon  males  as  well  as  females  showed  Providence  to  be  no  respecter 
of  persons.  One  man  had  a  pregnancy  in  the  thigh  because  he  laughed 
at  his  wife  in  her  suffering  during  labor.  It  is  said  that  the  products 
of  these  tumors  were  sometimes  baptized  in  the  hope  of  avoiding  the 
perdition  in  which  they  would  be  involved  without  such  a  ceremony. 
Hence,  it  seemed  that  the  priests  believed  in  their  own  invention, 
and  that  the  theory  was  not  a  mere  trick  with  which  they  tried  to 
practice  upon  the  credulity  and  ignorance  of  the  people. 

45 


706  OVARIAX   TUMORS. 

III.  As  the  knowledge  of  physiology  advanced  somewhat  among 
the  profession,  the  theories  became  more  rational,  and  the  possibility 
of  natural  causes  was  employed  to  explain  the  occurrence  of  these 
singular  tumors. 

They  were  regarded  by  many  as  ovarian  pregnancy,  in  which  the 
formation  of  the  foetus  was  imperfect,  or,  after  having  undergone 
development,  the  foetus  had  become  disintegrated,  and  the  skin,  bones, 
and  teeth  being  more  difficult  of  destruction,  had  withstood  decom- 
position and  remained  in  the  sac.  Another  theory  accounted  for 
their  peculiarities  b}^  supposing  that  the  ovum  had  become  blighted 
after  having  been  developed  to  a  certain  extent. 

Some  one  else  has  propagated  the  doctrine  of  inclusion,  or  of  a 
foetus  in  foetu,  believing  that  somehow  one  ovum  had  become  en- 
gulphed  in  the  organization  of  the  other,  and.  on  account  of  the  nature 
of  its  nidus  could  not  attain  to  complete  organization  or  develop- 
ment. 

Still  later,  plastic  heterology  and  heterotopy  were  supposed  to  afford 
a  more  rational  explanation  of  their  production.  According  to  this 
theory,  the  origin  of  these  tumors  in  any  part  of  the  body  is  no  more 
wonderful  than  the  growth  of  other  forms  of  heterologous  tumors  in 
the  same  localities. 

In  the  light  of  the  patient  physiological  research  of  our  own  day, 
and  especially  from  the  revelations  of  the  microscope,  a  theory  of  these 
curious  tumors  has  been  developed,  which  I  regard  by  far  the  most 
satisfactory  and  scientific. 

This  theory  is  based  upon  a  supposition  which  is  at  least  physio- 
logically plausible.     It  may  be  stated  thus  : 

In  the  early  period  of  ovulation  or  embryonic  development,  by 
some  accident  or  imperfection  of  formation,  an  indentation  of  the 
blastoderm  is  produced.  In  the  wonderful  trophic  energy  of  that 
period  the  minute  depression  is  inclosed  by  the  approximation  of  its 
blastodermic  margin  and  becomes  an  isolated  cavity,  and  the  growth 
and  perfection  of  the  embryo  are  accomplished  notwithstanding  this 
early  accident  to  the  integrity  of  its  envelope.  The  depression  thus 
formed  involves,  perhaps,  all  the  layers  of  the  blastodermic  membrane, 
but  the  external  layer  becomes  the  lining  membrane  of  the  cavity, 
and  is  completely  cut  off  from  the  rest  of  the  blastodermic  surface 
and  invaginated  with  all  its  essential  structures  and  processes  of 
organization  ;  all  its  products,  therefore,  must  be  retained  in  the  cavity. 
The  contents  of  this  cavity  correspond  in  miniature  with  what  the 
formation  might  have  been  if  the  displacement  had  not  occurred.  In 
the  further  development  of  the  embryo  the  portion  of  the  blastoderm 
covering  this  adventitious  cavity  develops  its  tissues  and  organs  in 
the  ordinary  way,  and  thus  incloses  it  in  the  body  by  the  structures 
usually  found  to  cover  it.     The  internal  layer  of  the  blastoderm  is 


NATUEE   AND    ANATOMY.  707 

doubtless  also  displaced,  but  it  is  not  isolated,  and  consequently  its 
products  are  never  found  inside  the  tumor.  Therefore,  in  instances 
where  the  dermoid  patch  occupies  any  of  the  mucous  cavities,  the 
neoplasm  will  always  be  found  external  to  the  mucous  membrane. 
This  theory  serves  to  explain  why  these  hairy  tumors  are  found  in 
the  foetus,  child,  virgin,  matron,  or  male,  and  with  equal  plausibility 
why  they  may  exist  in  any  part  of  the  body. 

Dr.  Pauly,  in  an  excellent  paper  in  the  American  Journal  of 
Obstetrics,  expresses  a  doubt  whether  they  exist  more  frequently  in 
the  ovary  than  elsewhere,  notwithstanding  the  generally  received 
opinion  that  this  is  the  case,  and  at  present  it  cannot  be  asserted  that 
they  are  not  as  common  in  the  male  as  in  the  female.  This  theory 
would  certainly  not  furnish  us  with  reasons  for  their  occurrence  more 
frequently  in  woman  than  in  man. 

If  nothing  unusual  happens  the  adventitious  sac  grows  with  the 
individual  in  whom  it  is  situated,  and  perhaps  attains  maturity  as  the 
same  character  of  organs  mature  elsewhere.  The  sac  itself  continues 
to  increase  in  size,  because  of  the  constant  secretion  of  the  glands  of 
the  dermic  structure.  Growth  from  this  cause  would  probably  be 
slow  if  the  activity  of  the  tegumentary  glands  were  not  preternatu- 
rally  quickened  by  morbific  causes.  When  situated  in  the  ovary, 
however,  the  conditions  naturally  calculated  to  impart  an  impetus, 
exclusive  of  what  is  termed  pathological  states,  exist.  Hence  in 
them  they  grow  more  rapidly  and  larger  than  in  other  places  or 
organs.  The  fluctuation  of  nerve  force,  circulatory  supply,  and 
nutritional  conditions  which  take  place  in  the  ovaries  in  consequence 
of  the  processes  of  menstruation,  sexual  excitement,  and  the  varied 
states  of  generation,  disturb  the  states  of  these  otherwise  nearly  sta- 
tionary neoplasms. 

These  reasons  would  lead  us  to  expect  the  dermoids  situated  in  the 
ovaries  to  become  large  and  to  grow  more  rapidly  than  in  any  other 
organ  or  locality.  When  situated  in  these  bodies  their  progress  is 
usually  tardy  until  the  age  of  puberty  is  reached.  At  this  time  the 
tumor  is  likely  to  be  influenced  by  the  increased  nervous  and  vascular 
activity  assumed  by  the  ovary,  and  thenceforward  they  manifestly 
possess  all  the  conditions  necessary  to  cause  copious  dermic  secretions. 
In  the  ovaries,  also,  their  growth  is  more  likely  to  be  influenced  by 
the  morbid  impressions  to  which  these  organs  are  more  frequently 
subjected  than  almost  any  other  part  or  organ  of  the  body.  They 
are  also  doubtless  especially  stimulated  by  the  occurrence  of  the  con- 
ditions which  give  rise  to  the  colloid  tumors.  For  in  connection 
with  this  form  of  tumor  they  are  generally  found  to  have  assumed 
great  proportions. 

The  conditions  imparted  to  dermoid  tumors  by  the  ovaries  would 
almost  necessarily  lead  to  their  discovery  during  the  lifetime  of  the 


708  OVARIAN   TUMORS. 

patient,  and  thus  favor  the  idea  that  they  are  more  frequently  located 
in  these  organs.  Situated  in  organs  of  more  unvarying  functions 
they  would  be  likely  to  remain  dormant,  and  never  attain  dimensions 
that  would  cause  them  to  be  discovered ;  consequently  they  are  over- 
looked in  the  general  statistics  on  the  subject. 

After  ovarian  tumors  have  been  developed  to  a  certain  extent 
they  become  subject  to  diseases  and  accidents,  and  thus  play  an  im- 
portant part  in  the  sanitary  conditions  of  patients  in  whom  they 
exist.  Inflammation  attacks  them,  and  causes  ulceration  in  their 
walls  so  as  even  to  perforate  them,  making  a  communication  between 
the  cavities  of  contiguous  cysts,  or  with  the  peritoneal  cavity.  With- 
out perforating  the  walls  of  the  tumor,  the  ulceration  may  produce  a 
good  deal  of  pus,  which  is  mingled  with  the  other  contents  of  the 
C3^st  in  which  it  occurs.  General  inflammation  of  its  walls  may  pro- 
ceed to  a  fatally  exhaustive  extent,  or  spread  to  the  peritoneum,  and 
thus  indirectly  cause  death.  Gangrene  may  also  result,  which  may 
be  confined  to  the  cavity  of  some  of  the  cysts,  and  induce  a  putrid, 
offensive  state  of  the  contents,  or  perforate  the  dividing  partitions, 
and  thus  make  a  communication  between  cysts,  or  open  them  into  the 
peritoneal  cavity.  The  walls  may  also  rupture  from  distension  in 
consequence  of  their  becoming  attenuated,  or  as  the  effect  of  a  violent 
stroke  or  fall,  or  other  shock,  and  the  contents  escape  into  the  perito- 
neal cavity.  By  means  of  ulcerative  communication  with  the  Fallo- 
pian tubes  the  fluid  sometimes  escapes.  Adhesion  to  the  walls  of  the 
abdomen  from  inflammation  and  ulceration  through  the  parts  thus 
agglomerated  sometimes  results,  and  the  fluid  so  discharged.  Inflam- 
mation also  causes  adhesion  at  various  parts.  The  fibrin  effused 
glues  it  to  the  surrounding  parts, — the  abdominal  walls,  the  intestinal 
canal,  bladder,  and  other  viscera.  Slight  inflammation  is  supposed 
to  increase  the  effusion  in  their  cavities,  and  cause  them  to  grow  very 
rapidly.  Inflammation,  also,  sometimes,  no  doubt,  causes  oblitera- 
tion of  the  cavity  from  adhesion  of  the  walls.  This  is  more  frequently 
the  case  when  it  results  from  external  causes,  as  blows,  tapping,  pres- 
sure, injection,  etc.  Now,  it  hardly  ever  happens  that  these  diseased 
conditions  and  accidents  of  the  tumors  fail  to  produce  their  effects 
upon  the  health  of  the  patient.  No  doubt  but  that  death  occurs  from 
extensive  disease  in  the  sac,  without  any  organ  being  directly  involved. 
A  large  production  of  pus  would  exhaust  the  patient;  gangrene,  to  a 
large  extent,  would  cause  death,  as  extensive  gangrene  of  unimportant 
organs  generally  does.  But  an  extension  of  disease  to  the  peritoneum 
and  surrounding  viscera,  or  by  the  effusion  of  the  acrid  contents  of  a 
diseased  cyst,  is  more  likely  to  be  the  mode  of  progress  to  constitu- 
tional disturbances  inaugurated  by  inflammation  in  the  tumors. 

When  the  tumor  bursts,  and  its  contents  are  effused  into  the  peri- 
toneal cavity,  the  peritoneum  seldom  escapes  without  inflammation ; 


NATURE    AND    ANATOMY.  709 

but  the  degree  will  depend  upon  the  nature  of  its  contents.  If  they 
are  not  vitiated,  but  consist  of  the  bland  albuminous  fluid  found  there 
ordinarily,  it  is  very  slight  indeed,  and  lasts  for  a  very  short  time  only. 
But  should  pus,  or  the  ichor  of  decomposition,  be  mingled  with  it,  we 
should  be  prepared  to  expect  serious  if  not  fatal  results. 

I  once  had  an  opportunity  of  observing  the  progress  of  a  case  for 
several  months,  where  this  rupture  and  effusion  were  frequently  re- 
peated. About  every  three  weeks  the  woman  would  attain  to  a  large 
size,  and  a  well-defined  large  cyst  could  be  felt  filling  up  the  whole 
abdomen  and  distending  it  greatly,  when  suddenly,  without  premoni- 
tion or  apparent  cause,  the  cyst  would  give  way,  the  swelling  would 
become  more  diffuse,  fluctuation  more  obvious,  and  the  cyst  could 
be  no  longer  defined  by  the  touch  ;  slight  fever  and  some  tenderness 
of  the  abdomen  would  last  for  two  or  three  days,  when  copious  per- 
spiration and  diuresis  would  evacuate  the  fluid  in  a  few  days  more. 
After  this  process  was  completed,  the  abdomen  would  be  lank,  and  a 
small  cyst  could  be  felt  rising  up  from  the  left  ilium  ;  it  would  in- 
crease and  burst  at  the  end  of  three  weeks,  as  the  other  had  done  before. 
I  saw  the  patient  frequently  while  this  process  was  repeated  six  or 
seven  times,  when,  as  she  would  not  submit  to  the  operative  proce- 
dure which  I  insisted  upon,  I  was  dismissed,  and  an  irregular  prac- 
titioner, who  was  sure  he  could  cure  her,  installed  in  my  place.  Not 
long  (perhaps  three  months)  after  I  was  discharged  she  died  from  the 
inflammation  resulting  from  one  of  these  effusions,  probably  because 
the  contents  of  the  cyst  had  become  vitiated  by  inflammation. 

But  these  growths  may  produce  a  pathological  condition  of  the 
system  without  becoming  themselves  the  seat  of  disease,  by  the  great 
size  they  may  attain  mechanically  interfering  Avith  the  functions  of 
the  pelvic  and  abdominal  viscera.  Before  rising  out  of  the  pelvis  it 
may  displace  the  uterus,  and  cause  inconvenience  from  this  effect ;  it 
may  press  upon  and  obstruct  the  rectum,  bladder,  and  urethra,  or 
upon  the  iliac  veins,  causing  obstruction  to  the  flow  of  blood,  and 
varicose  veins  in  the  legs,  phlebitis,  or  phlegmasia  dolens ;  or  pressing 
upon  the  nerves,  cause  neuralgic  pains  in  the  limbs,  hips,  etc.  It  is 
plain  that  such  pathological  eff'ects,  when  induced,  would  be  serious, 
in  proportion  with  the  greater  or  less  impaction  in  the  pelvis  by  its 
continued  growth.  Ordinarily,  these  inconveniences  do  not  prove 
very  embarrassing  to  the  functions  of  the  important  vital  organs,  but 
sometimes  the  case  is  far  otherwise,  and  life  is  very  much  shortened 
and  health  rendered  miserable.  As  it  rises  into  the  abdomen  these 
mechanical  troubles  are  apt  to  be  lessened  ;  and  as  the  room  is  com- 
paratively so  great  in  that  cavity,  quite  a  while  elapses  before  any 
great  disturbance  results  from  mechanical  pressure.  After  awhile, 
however,  the  abdominal  muscles  are  distended  beyond  convenient 
size,  and  the  tumor  is  strongly  pressed  among  the  viscera.     The  kid- 


710  OVARIAN  TUMORS. 

neys,  liver,  stomach,  intestinal  tube,  in  fact,  all  the  abdominal  organs, 
may  become  the  subject  of  great  and  even  fatal  pressure.  In  many 
instances,  however,  enormous  size  is  attained  before  fatal  damage  re- 
sults. One  hundred  and  fifty  pints  of  fluid  have  been  taken  at  a  single 
tapping.  A  much  less  amount,  in  most  cases,  would  produce  very 
grave  results  by  pressure.  When  the  growth  is  rapid,  its  mechanical 
effects  will  be  more  distressing;  and,  on  the  contrary,  the  organs 
accommodate  themselves  to  a  great  deal  more  pressure  if  gradually 
brought  about. 

Besides  the  inflammatory  changes  that  take  place  in  the  tumor, 
chronic  degeneration  is  occasionally  observed.  Deposits  of  earthy 
substances  in  the  walls,  bony  spiculse,  etc.,  are  the  most  frequent. 
Small  tumors,  containing  solid  material,  are  more  commonly  thus 
affected. 

Modes  of  Termination. 

The  modes  of  termination  are  worthy  of  some  consideration.  Many 
cases,  in  consequence  of  a  low  grade  of  vitality,  last  through  a  great 
many  years  without  materially  influencing  the  general  health,  and  up 
to  the  death  of  the  patient,  at  an  advanced  age,  when  large,  prove  to 
be  nothing  more  than  an  inconvenient  burden,  and  when  small  not 
the  cause  of  even  this  kind  of  trouble.  Others,  in  consequence  of  their 
bouitteous  vascular  supply  and  energetic  vitality,  bring  about  fatal 
conditions  of  the  abdominal  organs  in  a  few  months.  Spontaneously 
favorable  terminations  are  so  rare  that  we  can  base  no  calculation 
upon  them.  Perhaps  rupture  of  the  sac  into  the  peritoneal  cavity,  col- 
lapse, and  adhesion  of  its  walls,  is  the  most  common  and  favorable 
spontaneous  termination.  After  the  rupture,  in  cases  where  cure  fol- 
lows, it  is  probable  that  the  opening  in  the  sac  continues,  and  as  a 
permanent  fistula  from  the  cyst  into  the  peritoneum,  places  the  fluid 
in  contact  with  a  more  active  absorbing  surface,  until,  by  the  elasticity 
of  its  walls,  it  contracts  to  annihilation,  or,  at  the  first  shock  of  the 
rupture,  inflammation  is  originated  that  causes  an  obliteration  of  the 
cavity  of  the  sac.  Dr.  Simpson  speaks  of  instances  of  evacuation 
through  the  vagina.  The  same  thing  might  occur  in  connection  with 
the  bladder  or  alimentary  canal.  I  have  already  spoken  of  adhesion 
to  and  rupture  through  the  walls  of  the  abdomen,  and  consequent 
recovery.  Inflammation  in  its  proper  tissues,  no  doubt,  sometimes 
arrests  the  development  of  and  obliterates  the  tumor  without  mate- 
rially aff'ecting  the  patient's  general  health.  It  is  not  improbable  that 
other  circumstances  with  which  we  are  not  acquainted  may  likewise 
operate  to  cause  the  arrest  and  cure  of  them,  inasmuch  as  they  unques- 
tionably do  sometimes  disappear  in  an  unaccountable  manner. 

The  local  pressure  interfering  with  the  functions  of  the  bladder  and 


TERMINATION.  711 

rectum  may  induce  complicating  diseases  that  lead  to  death,  and  con- 
sequently cause  death  before  the  tumor  is  very  largely  developed. 
Inflammation  will  spread  upon  these  organs  to  their  more  vital  con- 
nections and  relative  organs ;  or,  by  interfering  with  excretion  from 
the  bowels  or  bladder,  produce  disease  of  the  blood,  and  thus  gradu- 
ally undermine  the  health  of  the  patient. 

After  the  tumor  has  ascended  into  and  greatly  distended  the  ab- 
dominal cavity,  pressure  upon  the  viscera  will  sometimes  produce 
disastrous  terminations.  The  stomach  is  crowded  into  a  very  small 
space,  food  can  be  taken  but  sparingly,  and  is  often  rejected  before 
digestion  is  completed.  The  vascular  supply  of  this  organ  is  cramped, 
and  its  secretions  vitiated  and  embarrassed,  and  in  this  way  digestion 
is  interfered  with,  the  appetite  destroyed,  and  loathing  of  food  takes 
its  place. 

Pressure  upon  the  vena  porta  embarrasses  the  secretion  of  the  liver. 
Pressure  upon  the  ductus  choledochus,  gall-bladder,  and  duodenum 
stops  the  excretion  of  bile;  it  is  dammed  back  upon  the  gland,  ab- 
sorbed, and  thrown  into  the  blood  to  poison  the  nervous  centres. 

There  is  no  doubt,  also,  that  the  general  compression  of  the  organs, 
by  pressure  upon  the  chyle  absorbents,  prevents  that  fluid  from  pass- 
ing as  freely  as  usual  into  the  blood,  and  thus  by  degrees  starves  the 
patient.  But  probably  no  more  disastrous  effects  of  the  pressure  of 
the  tumor  in  the  abdomen  is  noticed  than  such  as  is  produced  through 
the  kidneys.  Pressure  upon  the  emulgent  veins  causes  congestion  of 
the  kidney,  retention  of  urea  and  other  matters  that  should  be  excreted, 
and  drains  off  the  albumen  with  the  urine,  until  the  blood  becomes 
thinned  enough  to  infiltrate  into  the  cellular  tissue  in  the  form  of 
oedema  of  the  extremities,  or  into  the  peritoneal  cavity,  giving  rise  to 
ascites.  But  this  is  not  the  worst  mischief,  perhaps,  caused  by  the 
pressure  on  the  kidneys.  The  poisoning  of  the  blood  with  urea,  and 
its  effect  on  the  nerves  and  vital  organs,  is  too  well  known  to  require 
more  than  mere  mention  to  suggest  the  rapidly  fatal  tendencies  which 
result  from  it. 

Inflammation  in  any  of  the  important  abdominal  organs  may  be 
caused  by  the  pressure,  which  will  terminate  fatally  in  a  greater  or 
less  time,  owing  to  its  acuteness  or  slowness  of  progress.  It  will  be 
seen  by  the  above  that  ovarian  disease  usually  terminates  by  inducing 
a  long  train  of  distressing  constitutional  symptoms.  They  are  not 
uniform,  some  persons  suffering  from  one  mode  of  complication  and 
some  from  another ;  but  nearly  all  are  pretty  sure  to  experience  those 
terrible  sufferings  which  are  connected  with  secondary  disturbances  in 
the  vital  organs. 

The  presence  of  the  tumor,  when  not  large  enough  to  press  upon 
the  organs  sufliciently  to  do  very  much  damage,  sometimes  leads  to 
copious  dropsical  effusion  in  the  peritoneal  cavity.     This  is,,  at  least 


712  OVAEIAX    TUMORS. 

sometimes,  the  result  of  an  influence  exerted  upon  the  peritoneum, 
causing  it  to  secrete  more  than  an  ordinary  amount  of  serum. 

One  case  upon  which  I  operated  and  evacuated  a  large  amount  of 
serum  from  the  peritoneal  sac  recovered  completely  from  the  opera- 
tion, but  died  about  two  months  after  from  extreme  abdominal  dis- 
tension, in  spite  of  alteratives  and  diuretics. 

Causes. 

It  is  extremely  doubtful  whether  there  is  anything  in  the  general 
condition  of  the  patients  that  predisposes  to  the  development  of 
ovarian  tumors.  There  is  quite  a  disposition,  however,  with  certain 
authors,  as  will  be  apparent  to  any  careful  reader,  to  trace  most  chronic 
enlargements  to  scrofulous  taint  in  the  system  ;  and  these  gentlemen 
express  the  belief  that  scrofula  predisposes  to  ovarian  disease.  I  think 
we  may  very  safely  conclude  that  in  the  function  of  menstruation  we 
have  a  predisposing  cause  of  ovarian  disease.  It  is  true  that  ovarian 
tumors  have  been  found  in  the  ovaria  of  infants  and  foetuses,  and  very 
aged  females  ;  but  this  probably  is  as  rare  an  exception  to  the  general 
rule — that  the}^  occur  during  menstrual  life — as  the  occurrence  of  men- 
struation in  infancy  and  old  age.  Some  circumstances  connected  with 
menstrual  life  appear  also  to  increase  the  predisposition.  Sixty-one 
per  cent.,  according  to  Dr.  West,  of  the  patients  were  married,  while 
only  twenty-nine  had  never  been  married.  After  making  allowances 
for  the  greater  proportion  of  women  at  twenty-five  who  are  married, 
I  think  that  we  may  fairly  infer  that  marriage  adds  somewhat  to  the 
chances  of  the  occurrence  of  ovarian  dropsy. 

That  patients  who  are  the  subjects  of  this  disease  should  be  less 
likely  to  have  children  than  those  in  whom  ovulation  is  more  perfect 
and  complete,  will  not,  I  think,  justify  us  in  setting  down  sterility  as 
the  cause  of  it  in  any  way,  but  it  is  more  probably  connected  as  an 
effect.  During  menstrual  life  the  most  obnoxious  time  is  between  the 
ages  of  twenty-five  and  forty,  the  time  when  the  sexual  functions  are 
exercised  with  more  activity  than  any  other. 

Unhealthy  menstruation  seems  to  be  more  commonly  coincident 
with  it  than  healthy.     Abortions  and  premature  labor  are  so  likewise. 

We  should  attach  sufficient  importance  to  the  fact  that  it  occurs  in 
unmarried  persons  as  often  as  twenty-nine  percent.  This  induces  Dr. 
West  to  remark,  that  "  it  occurs  in  the  unmarried  oftener  than  any 
other  organic  disease  of  the  sexual  organs." 

The  exciting  or  proximate  causes  are  such  as  excite  the  ovaria  and 
induce  abortive  efforts  at  ovulation.  What  does  so  avc  are  not  able  to 
say  with  certainty,*  probably  chronic  inflammation. 

Inflammation   of  a  low  grade,  and   somewhat   chronic  duration, 

*  See  Chronic  Ovaritis. 


PROGNOSIS.  713 

might  cause  induration  or  thickening  of  the  indusium,  so  that  it  would 
not  yield  to  the  upheaving  pressure  of  the  ovisac  and  permit  dehis- 
cence. 

The  probabilities,  I  think,  are  in  favor  of  this  mode  of  merging  a 
healthy  into  an  unhealthy  accumulation.  When  once  thus  commenced, 
the  stimulus  of  increased  incretion  of  fluid  would  carry  oii  a  kind  of 
hypertrophy  in  the  involucra  that  would  permit  of  a  further  enlarge- 
ment. The  local  circumstances  regarded  as  the  causes  of  the  disease 
would  favor  the  occurrence  of  inflammation,  and  are  very  frequently 
attended  with  some  of  the  symptoms  of  it.  The  ovary  and  uterus, 
during  each  menstrual  period,  are  often  attended  with  pain  in  the 
ovarian  region  of  just  such  a  character  as  we  would  expect  to  indicate 
inflammation.  This  ovarian  pain  is  present  in  other  excited  con- 
ditions of  the  sexual  organs  also,  thus  showing  that  they  are  often 
the  focus  of  painful  vascular  turgescence,  if  not  inflammation.  While 
inflammation  is  probably  the  cause  of  the  beginning  of  the  develop- 
ment of  ovarian  tumors,  it  does  not  seem  necessary  to  their  continued 
development,  as  the  accumulation  of  fluid  in  a  shut  cavity,  with  a 
secreting  internal  surface,  is  a  matter  of  course,  and  the  limit  of  its 
amount,  for  the  most  part,  does  not  depend  upon  anything  but  the 
capacity  of  the  involucra  to  grow,  until  interrupted  by  external  cir- 
cumstances. 

Although  inflammation  may,  in  most  cases,  be  the  cause  of  the 
toughness  of  the  covering  to  the  ovary,  which  prevents  the  escape  of 
the  ovum,  this  condition  may  result  from  some  other  local  circumstance. 
Congenital  formation  may  be  such  as  to  permit  the  involucra  to  in- 
crease as  fast  as  the  demand  for  more  room  becomes  necessary. 

Prognosis. 

Our  knowledge  with  regard  to  the  prognosis  is  unfortunately  too 
definite.  There  is  no  need  of  much  conjecture  with  reference  to  this 
matter  ;  the  termination  is  too  frequently,  demonstrated.  In  arriving 
at  prognosis  with  reference  to  any  disease,  we  ought  to  consider 
whether  its  ordinary  course  is,  after  a  time,  to  a  termination  in  health, 
as  is  the  case  with  many  diseases,  or,  there  being  no  such  favorable 
tendency,  what  are  the  probabilities  of  a  cure.  Unfortunately,  there 
is  almost  no  tendency  to  spontaneous  recovery  in  ovarian  drops}'- ; 
probably  not  two  per  cent,  but  would,  after  a  longer  or  shorter  time, 
terminate  in  the  death  of  the  patient.  While  this  is  the  case,  it  does 
not  properly  represent  the  value  of  a  life  threatened  by  this  aff'ection. 
Some  patients  live  a  great  many  years  in  comparative  comfort;  but, 
by  large  odds,  the  case  is  generally  very  diff"erent, — onl}^  a  few  years 
being  suflicient  to  finish  the  course  in  a  downward  direction.  The 
average  duration  of  life  is  about  three  years  from  the  time  it  is  first 
perceived. 


714  OVARIAN   TUMORS. 

We  should  carefully  examine  every  indhHdual  case  with  reference 
to  its  own  peculiarities,  its  nature,  and  the  character  and  condition  of 
the  patient.  Is  the  disease  sim23le,  or  a  compound  of  cyst  and  solid, 
polycystic  or  monocystic?  The  monocystic  is  very  much  more  favor- 
able for  treatment,  and  terminates  in  spontaneous  recovery  oftener 
than  the  polycystic.  The  duration  of  life  is  greater,  also,  in  the  mono- 
cystic. If  several  years  have  elapsed  since  the  patient  was  aware  of 
the  presence  of  the  tumor,  it  will  probably  continue  to  increase  slowly, 
unless,  as  is  sometimes  the  case,  more  activity  has  lately  been  ob- 
served, so  that  a  tumor  that  had  formerly  grown  very  slowly,  and 
required  a  number  of  years  to  acquire  half  its  size,  has  grown  the  rest 
in  a  few  months.  In  this  last,  there  is  every  probability  of  a  rapidly 
fatal  course.  Again,  if  the  patient  has  not  known  any  increase  of  size 
until  within  a  few  months  past,  and  yet  is  quite  large,  the  prognosis 
is  bad.  Our  prognosis  is  influenced  by  age  to  a  considerable  extent ; 
occurring  in  young  persons,  it  is  more  likely  to  advance  rapidly  than 
in  old  ones.  A  woman  at  forty  is  not  apt  to  develop  an  ovarian 
dropsy  so  rapidly  as  one  at  from  sixteen  to  twenty. 

Ovarian  dropsy  will  advance  less  rapidly  after  menstruation  ceases 
than  before,  and  the  earlier  in  menstrual  life  the  more  rapidly  it  will 
advance.  The  prognosis,  as  a  general  thing,  therefore,  is  worse  in  the 
young  than  the  old.  If  we  should  decide  the  question  by  age  how 
long  will  she  live,  we  should  speak  more  favorably  to  the  woman 
advanced  in  years. 

The  inflammation,  the  pressure  upon  the  rectum,  bladder,  stomach, 
bowels,  and,  above  all,  the  kidneys,  the  nervous  system,  the  vascular 
system,  nutrition,  as  shown  by  the  signs  of  emaciation  or  otherwise, 
should  all  be  carefully  scrutinized. 

Diagnosis. 

The  diagnosis  of  ovarian  tumors,  when  tolerably  large,  and  not 
complicated  with  more  than  ordinarily  embarrassing  circumstances, 
is  not  difficult ;  but  instances  do  occur  where  the  matter  is  far  other- 
wise, and  a  positive  opinion  cannot,  with  propriety,  be  given. 

Remarks  on  Diagnosis  of  Ovarian  Tumors  Generally. 

The  history  will  aff'ord  us  in  many  cases,  hoAvever,  very  valuable 
aid  in  arriving  at  correct  conclusions.  It  is  now  pretty  well  deter- 
mined that  the  average  duration  is  about  three  years.  In  this  time 
it  will  spontaneously  produce  fatal  effects,  by  great  size  and  extreme 
distension,  and  the  resulting  damage.  This  is  longer  than  pregnancy 
lasts,  and  a  shorter  time  than  is  required  for  solid  fibrous  growths  to 
reach  the  same  results.  The  age  at  which  they  are  most  likely  to 
occur  is  an  average  of  twenty-six  years,  according  to  Mr.  Brown, 


PHYSICAL    EXAMINATION.  715 

although  they  may  occur  at  any  time  during  the  active  condition  of 
the  sexual  functions,  while  the  ovaria  are  subject  to  menstrual  con- 
gestions and  their  effects.  Quite  a  large  number  of  cases  make  their 
first  appearance  in  early  menstrual  life.  In  rare  instances  they  are 
congenital  and  show  themselves  in  infancy  and  childhood.  Fibrous 
growths  of  the  uterus  are  not  likely  to  begin  so  soon.  Their  increase 
after  being  first  observed  is  comparatively  rapid,  more  so  in  the  young 
than  those  somewhat  advanced  in  age.  They  are  not  usually  at- 
tended with  pain  in  their  own  proper  substance ;  this  is  not  always 
true,  for  the  congestion  and  hyperexcitement  may  be  attended  with 
pain  and  soreness.  Functional  disturbances  in  their  early  stages  often 
occur  in  the  pelvic  viscera ;  first,  on  account  of  pressure,  such  as 
tenesmus,  dysuria,  dragging,  or  weight  in  the  pelvis ;  and  secondly, 
imperfect  menstruation.  Sometimes  the  menses  are  suppressed,  scanty, 
and  painful,  but  often  no  deviation  is  observed.  The  main  thing  in 
the  history  of  the  case,  in  this  respect,  is  to  remember  that  the  symp- 
toms point  in  the  beginning  to  trouble  in  the  pelvis.  It  is  generally, 
or  at  least  sometimes,  stated  that  the  tumor  rises  from  one  iliac  region 
and  continues  to  occupy  one  side  for  some  time.  This,  I  think,  is 
the  exception  to  the  rule,  and,  by  Dr.  Frederick  Bird,  is  considered 
an  evidence  of  adhesion.  When  large  enough  to  overcome  the  sup- 
port of  their  peritoneal  envelope,  they  fall  into  the  cul-de-sac  of 
Douglas,  and,  as  they  grow,  come  up  in  front  of  the  promontory  of 
the  sacrum,  until  large  enough  to  be  felt  above  the  pubis,  having 
their  point  of  support  in  the  hollow  of  the  sacrum,  instead  of  one  of 
the  iliac  fossae.  The  patient  will  usually  speak  of  it  as  a  lump,  in- 
stead of  saying  that  she  is  swollen,  as  in  pregnancy.  She  has  watched 
it  coming  up  out  of  the  pelvis,  and  not  starting  from  above  or  from 
one  side,  and  encroaching  upon  the  abdomen  from  either  of  those 
directions. 

Physical  Examination. 

The  knowledge  derived  by  physical  examination  is  the  most  valu- 
able ;  and  while  the  modes  of  procedure  are  the  same,  and  applicable 
to  all  stages  of  growth  and  enlargements  of  the  tumor,  we  will  be  able 
better  to  describe  and  understand  them,  as  made  use  of  for  one  that 
has  arisen  from  the  pelvis,  and  more  or  less  thoroughly  filled  the 
abdominal  cavity, — a  tumor  that  has  become  obvious,  and  from  which 
our  patient  is  solicitous  of  being  relieved. 

The  means  afforded  us  for  physical  examination  are:  1st,  palpa- 
tion ;  2d,  percussion;  3d,  auscultation  ;  4th,  vaginal  and  rectal  digital 
examination;  5th,  examination  with  the  sound  or  uterine  probe. 
These  may  be  used  separately,  or  combined  in  any  given  case ;  some 
being  more  valuable  in  some  cases,  and  others  in  different  ones. 
Exploring  needles,  chemical  tests,  and  the  microscope  may  also  be 


716  OVARIAX   TUMORS. 

used  to  great  advantage.  Palpation  is  of  very  little  use  while  the 
tumor  is  still  in  the  pelvis,  except  in  conjunction  with  the  vaginal 
touch  or  the  uterine  probe;  as  it  rises  in  the  abdomen,  however,  this 
process  of  examination  comes  into  use  independently.  In  this  con- 
dition we  can  examine  the  consistence,  size,  shape,  and  mobility  of 
the  growth,  and  form  some  opinion  as  to  its  adhesion  to  the  walls  of 
the  abdomen,  and  its  primary  attachments. 

Palpation  and  Percussion. 

In  the  ordinary  condition  of  the  contents  of  the  abdomen  the  in- 
testines lie  in  contact  with  the  anterior  and  lateral  walls,  except  in 
the  right  and  left  hypochondria,  where  the  liver,  over  a  considerable 
space,  and  the  spleen,  a  smaller,  displace  them.  In  consequence  of 
this  state  of  things,  the  resonance  caused  by  the  gas  in  the  alimentary 
tube  extends  all  over  the  anterior  and  lateral  walls,  save  the  above 
exceptions.  Dulness  upon  percussion,  therefore,  indicates  the  presence 
of  a  tumor.  The  mesenteric  attachments  between  the  posterior  wall 
of  the  abdomen  and  intestinal  tube  prevent  them  from  being  separated 
from  the  spine  to  any  considerable  extent ;  hence  tumors  occupying 
much  space  are  apt  to  displace  and  get  anterior  to  the  latter.  If  the 
tumor  springs  from  the  pelvis  this  is  particularly  the  case,  as  well  from 
the  above  facts  as  the  direction  given  to  it  by  the  axis  of  the  superior 
strait ;  thus  it  is  with  the  gravid  uterus,  uterine  fibrous  growths,  and 
ovarian  enlargements.  Growths  from  the  pelvis,  perhaps,  more  com- 
pletely gain  the  anterior  position  than  any  other  sort,  unless  it  be  such 
as  are  attached  to  the  anterior  wall  originally.  It  may  be  observed, 
too,  that  it  takes  a  larger  growth  to  disengage  itself  from  intestinal 
resonance  when  arising  from  the  posterior  wall  than  from  any  other 
situation  in  that  cavity. 

By  percussion  we  may  make  out  the  boundaries,  positions,  and,  to 
some  extent,  attachment  and  contents  of  an  abdominal  tumor.  We 
should  begin  at  the  pubis,  and  follow  a  line  upward  to  the  ensiform 
cartilage ;  by  so  doing  we  will  ascertain  the  central  perpendicular 
extent.  A  good  plan  is  to  make  four  or  five  perpendicular  explora- 
tions of  this  kind  each  side  of  the  median  line,  extending  the  whole 
length  of  the  abdominal  cavity.  After  this  has  been  done  we  may 
proceed,  by  right  angles  to  these  lines,  to  examine  the  abdomen  cross- 
wise, from  its  lower  to  its  upper  boundary.  We  will  seldom  miss  any 
important  groWth  by  this  mode  of  proceeding.  If  there  is  any  doubt 
or  obscurity,  pressure  in  connection  Avith  percussion  should  be  suffi- 
cient to  bring  out  something  of  the  flatness  of  sound  from  the  spine, 
kidneys,  etc.  If  we  discover  any  point  of  sufficiently  defined  dulness 
to  impress  us  with  the  idea  of  a  tumor,  we  should,  by  percussing  ex- 
plorations, proceed  from  the  point  of  greatest  dulness  to  its  circumfer- 


PALPATION    AND    PERCUSSION.  717 

ehce  in  every  direction.  In  this  way  of  examining,  we  will  be  able  to 
trace  it  up  tbe  side  to  the  hypochondriac  regions  down  into  the  pelvis, 
or  define  it  so  perfectly  as  to  decide  what  must  be  its  place  of  origin. 
Another  valuable  method  of  employing  palpation  is  to  place  one  hand 
on  each  side  of  the  abdomen,  and  press  them  strongly  toward  each  other. 
If  there  is  a  tumor  its  resistance  to  their  approximation  will  demonstrate 
its  presence.  Percussion  and  palpation  will  often  enable  us  to  deter- 
mine the  contents  of  a  tumor  as  to  its  solidity  or  fluidity.  Placing 
the  finger  on  one  side  of  the  tumor,  while  we  percuss  the  other,  if  the 
contents  are  wholly  fluid,  a  wave  of  liquid  will  be  set  in  motion  on 
the  side  struck,  and  traverse  the  space  to  the  one  of  the  opposite ;  if 
solid,  of  course  nothing  of  this  kind  will  take  place,  and  the  impulse 
will  be  given  to  the  whole  substance  of  the  growth.  Should  the 
contents  be  fluid,  separated  by  a  number  of  partitions,  the  wave  or 
fluctuation  will  be  less  distinct  than  in  the  one  where  no  such  division 
exists  ;  but  in  fact  the  obscurity  is  so  great  that  we  will  be  at  a  loss 
by  this  management  to  decide  whether  the  contents  are  solid  or  fluid. 
A  slight  variation  of  this  combination  of  tact  and  percussion  will 
often  clear  it  up,  however.  When  we  wish  to  ascertain  whether  the 
fluid  is  contained  in  several  cysts,  we  should  place  the  pulp  of  the 
fingers  of  the  left  hand  in  the  centre  of  the  tumor,  and  then  percuss 
with  those  of  the  right,  first  very  near,  then  gradually  increase  the 
distance  between  them,  until  we  find  a  point  at  which  the  fluctuation 
becomes  less  distinct ;  this  is  the  margin  of  the  cyst  over  which  our 
left  fingers  are  placed.  Still  keeping  them  in  position,  we  percuss 
around  in  every  direction,  until  we  have  made  out  the  boundary  and 
size  of  the  cyst  under  examination,  when  we  may  move  the  fixed 
fingers  to  its  margin,  and  commence  the  same  process  around  this 
point.  Proceeding  in  this  way  from  one  point  in  the  abdomen  to 
another,  in  most  instances  we  may  trace  the  outline  of  all  the  cysts 
superficially  situated,  and  thus  enumerate  them,  and  learn  their  rela- 
tion and  absolute  size.  If  solid  bodies,  of  whatever  structure,  are 
incorporated  in  the  mass  and  superficially  situated,  they  may  be  de- 
tected with  their  relative  position,  size,  etc. 

After  tapping,  when  the  abdomen  is  lessened,  its  walls  lax  and 
soft,  palpation,  and  percussion,  singly  or  combined,  become  more 
demonstrative  than  before  this  operation.  It  not  unfrequently  is 
necessary,  on  account  of  the  sensitiveness  of  the  patient,  when  the 
tumor  is  small,  and  the  abdominal  muscles  not  much  under  control 
of  the  will,  to  administer  an  anaesthetic  until  unconsciousness  is  in- 
duced, a^d  the  influence  should  often  be  so  profound  as  to  abolish 
reflex  sensibility.  Palpation  and  percussion  should  both  be  practiced 
ordinarily  with  the  patient  in  the  recumbent  position  on  the  back, 
with  knees  drawn  up,  shoulders  elevated,  and  the  abdomen  stripped 
quite  bare  of  covering ;  in  many  instances,  however,  variation  of  post- 


718  OVARIAN   TUMORS. 

ure  is  indispensable  to  definite  results, — the  standing,  prone,  etc. 
Very  little  need  be  said  in  this  place  about  auscultation,  as  it  is  only 
applicable  to  the  diagnosis  between  it  and  pregnancy,  and  will  be 
dwelt  upon  when  I  come  to  speak  of  that  more  particularly.  Vaginal 
and  rectal  digital  examinations  in  ovarian  disease  are  proper,  and 
should  not  be  dispensed  with.  The  pelvis  should  be  carefully  sur- 
veyed by  this  method.  The  attachments,  consistence,  and  relations 
of  the  diseased  mass  to  the  various  organs  in  this  cavity  should  be 
carefully  noted.  The  uterus,  rectum,  and  bladder,  so  far  as  practica- 
ble, ought  to  be  examined  with  reference  to  their  healthy  condition, 
position,  and  involvement.  Combined  with  external  palpation,  we 
may  examine  the  tumor  more  thoroughly  than  with  either  one  alone. 
Two  fingers  introduced  into  the  vagina,  and  pressed  firmly  upward 
against  it,  will  perceive  any  impulse  imparted  to  the  tumor  above. 
With  the  left  hand,  if  we  press  downward  toward  the  pelvis,  we  may 
feel  the  motion  of  the  diseased  accumulation  downward,  and,  if  the 
sudden  impulse  of  percussion  is  applied  above,  we  may  feel  an  impres- 
sion from  its  contents ;  if  fluid,  a  wave  or  sense  of  fluctuation ;  if  solid, 
the  deadened  impulse  alwaj^s  given  in  such  cases.  When  the  tumor 
is  small,  and  occupies  the  posterior  peritoneal  cul-de-sac,  by  intro- 
ducing one  finger  in  the  rectum  and  the  other  into  the  vagina,  the 
tumor  ma}^  be  included  between  them,  and  thus  examined  with  more 
accuracy  than  with  either  alone. 

The  late  Sir  James  Y.  Simpson  taught  us  how  to  extend  our  exami- 
nations into  the  uterus,  so  that  our  information  in  this  direction  is 
very  materially  increased  by  the  use  of  the  probe  mounted  upon  a 
handle.  Members  of  the  profession  who  appreciate  the  labors  of  Dr. 
Simpson  have,  by  consent,  named  the  instrument,  the  improvements 
and  uses  of  which  he  has  so  ably  promulgated,  "  Simpson's  sound." 

The  sound  may  be  introduced  into  the  uterus,  and  varied  in  its 
direction,  while  we  gently  urge  it  forward  to  the  extremity  of  the 
uterine  cavity.  The  only  obstacle  a  sound  of  the  proper  size  will 
meet  with  in  a  uterus  of  ordinary  size  arises  from  want  of  correspond- 
ence with  the  direction  of  the  cavity.  The  most  simple  and  ready 
revelation  of  the  sound  or  probe  is  the  direction  and  length  of  the 
uterine  cavity.  From  this  knowledge  much  valuable  deduction  may 
be  drawn.  But  it  is  employed  for  determining  the  relation  of  the 
uterus  to  pelvic  tumors,  according  to  the  ingenious  directions  of  Dr. 
Simpson,  very  handily  and  to  excellent  purjDose.  While  the  sound 
is  in  the  cavity  of  the  uterus,  this  organ  may  be  fixed  by  holding  the 
instrument  firmly  in  one  position,  or  be  moved  in  any  direction,  if  not 
restrained  by  adhesion  or  accretional  attachment  to  the  diseased  mass, 
or  to  some  other  organ.  If  the  uterus  be  fixed,  and  the  tumor  moved 
by  its  side  or  from  it,  with  the  fingers  introduced  for  the  purpose,  the 
motion  will  be  felt  affectino-  the  uterus  through  the  attachments.     On 


EXPLORATION. 


719 


the  other  hand,  if  we  watch  the  motion  of  the  tumor  with  the  fingers 
while  the  uterus  is  moved,  the  attachment  or  not  will  be  determined, 
or  the  uterus  may  be  moved  in  one  direction  and  the  tumor  in  another. 
In  this  way  their  attachments  may  be  pretty  certainly  diagnosticated. 
The  sound  may  be  employed  in  the  uterus  with  one  hand,  while  pal- 
pation on  the  abdominal  surface  is  effected  with  the  other ;  and,  if  the 
uterus  reaches  above  the  pubis,  the  distance  the  probe  is  separated 
from  the  external  hand,  or  its  relation  with  the  median  line  of  the 
abdomen,  or  the  main  bulk  of  the  growth,  will  enable  us  to  determine 


Fig.  297. 


CODMAN  &  SHURTLEFF, 
BOSTON. 

Aspirator. 


some  interesting  problems.  The  motion  received  by  the  sound  from 
the  pressure  of  the  hand  without,  or  vice  versa,  is  of  important  signifi- 
cance, as  will  be  more  apparent  as  we  advance. 


Exploration. 

When,  from  all  these  sources  of  inquiry,  we  fail  to  get  a  sufficiently 
definite  answer,  there  is  still  another  physical  means  of  diagnosis 
which  we  are  justified  in  employing,  viz.,  exploration.  By  means  of 
an  exploring  needle,  or  aspirator,  we  can  draw  off"  a  small  quantity  of 
fluid,  which  may  be  subjected  to  microscopic  and  chemical  tests  that 
will  often  enable  us  to  determine  the  nature  of  the  disease. 

Dr.  J.  Hughes  Bennett,  in  a  paper  on  "  Ovarian  Disease,"  in  the 
Edinburgh  Medical  and  Surgical  Journal,  quoted  by  Mr.  Brown,  says,  as 
the  result  of  his  microscopic  "  examinations  of  different  specimens  of 
ovarian  fluid,  that  the  most  constant  characteristic  of  such  fluid  is  its 
containing,  in  greater  or  less  abundance,  cells  gorged  with  granules ; 
and,  in  addition,  circumambient  granules,  having  the  same  measure- 
ment as  those  encompassed  by  the  cell-wall.  At  one  time  I  considered 
the  size  of  these  granules  (if  they  can  properlv  be  so  called),  was  con- 


720  OVAEIAN   TUMORS. 

stant,  but  subsequent  observations  have  convinced  me  of  the  incor- 
rectness of  this  conchision ;  the  size  of  the  gorged  cells  and  granules 
varies  greatly,  even  in  the  fluids  from  different  cysts  of  the  same 
ovary."  There  can  be  no  question  but  that  the  nature  of  the  fluid 
contained  in  these  cysts  is,  in  all  its  essential  features,  pretty  con- 
stantly the  same  in  the  early  stages  of  progress ;  but  it  is  equally  true 
that,  as  they  grow  large  enough  to  be  influenced  by  pressure  or  other 
external  causes,  their  microscopic  composition  must  vary. 

Although  my  opportunities  for  microscopic  examination  of  ovarian 
fluid  have  been  quite  limited  as  compared  to  others,  I  cannot  but 
express  a  decided  belief  in  the  conclusion  arrived  at  by  Dr.  T.  M. 
Drysdale. 

I  have  never  found  the  ovarian  cell  described  by  Drysdale  in  any 
but  ovarian  fluid ;  nor  have  I  failed  to  find  it  in  specimens  that  I 
knew  to  be  fluid  from  an  ovarian  tumor.  It  is  but  fair  to  say,  how- 
ever, so  many  of  the  best  gynecologists  doubt  the  accuracy  of  his 
conclusions,  that  the  question  is  far  from  being  settled. 

The  fluid  drawn  from  the  tumor  is  generally  turbid  and  discolored, 
often  chocolate  color.  When  felt  between  the  thumb  and  finger  it  is 
sticky,  and  sometimes  very  tenacious  and  ropy. 

The  granular  cell  revealed  by  the  microscope,  according  to  Drys- 
dale, is  best  exhibited  in  contrast  with  other  pathological  products 
contained  in  the  sac,  as  given  in  the  plate  and  description  on  pages 
458-59  of  Ovarian  Tumors,  by  Dr.  W.  L.  Atlee. 

"  On  the  Granular  Cell  found  in  Ovarian  Fluid. 

"  On  placing  a  drop  of  the  fluid  removed  from  an  ovarian  cyst  under 
the  microscope,  we  usually  find  (Fig.  298)  a  number  of  granular 
cells,  E,  some  free  granular  matter,  c,  and  small  oil-globules,  b;  and 
frequently,  in  addition  to  these,  epithelial  cells  of  various  forms,  a, 
and  crystals  of  cholesterin,  d.  These,  together  with  blood-corpuscles, 
F,  the  inflammatory  globules  of  Gluge,  i,  the  pus-cell,  g  h,  and  disin- 
tegrated blood  and  other  cells,  may  all  be  sometimes  seen  floating  in 
either  a  clear  or  a  turbid  fluid. 

"  To  find  them  all  present  in  one  specimen,  however,  is  rare;  more 
commonly  we  can  discover  but  three  or  four  of  them  in  the  fluid. 
But  no  matter  what  other  cells  may  be  present  or  absent,  the  cell  which  is 
almost  invariably  found  in  these  fluids  is  the  granular  cell. 

"  This  granular  cell,  e,  in  ovarian  fluid  is  generally  round,  but 
sometimes  a  little  oval  in  form,  is  very  delicate,  transparent,  and 
contains  a  number  of  fine  granules,  but  no  nucleus.  The  granules 
have  a  clear,  well-defined  outline.  These  cells  differ  greatly  in  size, 
but  the  structure  is  always  the  same.  They  may  be  seen  as  small  as 
the  one  five-thousandth  of  an  inch  in  diameter,  and  from  this  to  the 


THE    OVARIAN    CELL.  721 

one  two-thousandth  of  an  inch.  In  some  instances  I  have  found 
them  much  larger,  but  the  size  most  commonly  met  with  is  about  that 
of  a  pus-cell  *     (Fig.  298.) 

"  The  addition  of  acetic  acid  causes  the  granules  to  become  more 
distinct,  while  the  cell  becomes  more  transparent.  When  ether  is 
added,  the  granules  become  nearly  transparent,  but  the  appearance 
of  the  cell  is  not  changed. 

"  This  granular  cell  may  be  distinguished  from  the  pus-cell,  lymph- 
corpuscle,  white  blood-cell,  and  other  cells  which  resemble  them, 
both  by  the  appearance  of  the  cell  and  by  its  behavior  with  acetic 
acid. 

"The  pus  and  other  cells,  g,  which  have  just  been  named,  have 
often  a  distinctly  granular  appearance;  but  the  granules  are  not  so 
clearly  defined  as  in  the  granular  cell  found  in  ovarian  disease,  owing 
to  the  partial  opacity  of  these  cells;  and,  when  the  granular  cell  of 
ovarian  disease  and  the  pus-cell  are  placed  together  under  the  micro- 
scope, this  difference  is  very  apparent.  In  addition  to  the  opacity 
of  these  cells,  we  frequently  find  their  cell-wall  appearing  wrinkled 
rather  than  granular ;  and  further,  in  the  fresh  state,  they  are  often 
seen  to  contain  a  body  resembling  a  nucleus. 

"  But  if  there  is  doubt  as  to  the  nature  of  the  cell,  the  addition  of 
acetic  acid  dispels  it ;  for  if  it  is  a  pus-cell,  or  any  of  the  cells  named 
above,  it  will,  on  adding  this  acid,  be  seen  to  increase  in  size,  become 
ver}'  transparent,  and  nuclei,  varying  in  number  from  one  to  four, 
will  become  visible.  (See  g,  pus-cell,  before  adding  acid;  and  h,  pus- 
cell,  after  adding  acid.)  Should  the  cell,  however,  be  an  ovarian 
granular  cell,  the  addition  of  this  acid  will  merely  increase  its  trans- 
parency and  show  the  granules  more  distinctly. 

"  The  compound  granular  cell,  i,  the  granule  cell  of  Paget  and  others, 
or  inflammation-corpuscle  of  Gluge,  is  also  occasionally  present  in 
these  fluids,  and  might  possibly  be  mistaken  for  the  ovarian  granular 
cell ;  but  it  is  not  difficult  to  distinguish  them  from  each  other.  Gluge's 
cell  is  usually  much  larger  and  more  opaque  than  the  ovarian  cell, 
and  has  the  appearance  of  an  aggregation  of  minute  oil-globules,  some- 
times inclosed  in  a  cell-wall,  and  at  others  deficient  in  this  respect. 
The  granules  are  coarser,  and  vary  in  size,  while  the  granules  of  the 
ovarian  cell  are  more  uniform  and  very  small.  By  comparing  them 
in  the  drawing,  these  differences  will  be  apparent.  Again  the  behavior 
of  these  cells  on  the  addition  of  ether  will  at  once  decide  the  ques- 
tion ;  for  while  the  ovarian  granular  cell  remains  nearly  unafl'ected  by 


*  "  By  comparing  the  drawing  of  tlie  ovarian  cell  which  accompanies  this  paper 
with  one  given  in  Dr.  Atlee's  work  on  Ovarian  Tumors,  it  will  be  seen  that  I  have 
omitted  the  three  large  dark  cells  which  form  the  left  of  the  group  representing  the 
ovarian  cell  in  that  drawing,  and  which  are  inaccurate." 

46 


'22 


OVARIAN    TUMORS. 


it,  or,  at  most,  has  its  granules  made  paler,  the  cell  of  Gluge  loses  its 
granular  appearance,  and  sometimes  entirely  disappears  through  the 
solution  of  its  contents  by  the  ether. 

"  That  the  discovery  of  a  granular  cell  in  ovarian  fluid  is  new  I  do 
not  assert,  as  J.  Hughes  Bennett  and  other  writers  have  described 
granular  cells  which  they  have  seen  in  these  fluids;  but,  with  one  ex- 
ception, their  description  does  not  correspond  with  the  ovarian  granu- 
lar cell.  Bennett,  for  instance  {Ed.  Med.  and  Surg.  Journ.,  vol.  Ixv,  p. 
280,  1846),  states  that  the  granular  cell  which  he  saw  exhibited  a  dis- 
tinct nucleus  on  the  addition  of  acetic  acid,  which  is  not  the  case  with 
this.     Other  writers  have  described  the  cells  which  they  found  as  pus 


Microscopic  Examination  of  Fluid  from  Ovarian  Tumors. 

and  pyoid  cells,  and  yet  others  confound  them  with  the  compound 
granular  cell  or  inflammation  globules.  The  exception  referred  to 
above  is  found  in  Beale's  description  of  the  microscopic  appearance 
of  ovarian  fluid.*    He  observes : 

"'The  cells  are  composed  of  at  least  two  distinct  forms:  1.  Small,  delicate,  trans- 
parent, and  faintly  granular  cells,  without  the  sligiitest  appearance  of  a  nucleus,  some 
being  somewhat  larger,  and  others  smaller,  than  a  pus-corpuscle.     2.  Large  cells,  often 


*  The  Microscope  in  its  Application  to  Practical  Medicine.     By  Lionel  S.  Beale, 
M.D.,  F.R.S.,  etc.    3d  edit.,  p.  179. 


DIFFERENTIAL    DIAGNOSIS.  723' 

as  much  as  the  thousandth  of  an  inch  in  diameter,  but  varying  in  size,  of  a  dark  color 
by  transmitted,  and  white  by  reflected  light.  These,  which  have  been  termed  "granu- 
lar corpuscles,"  "  compound  granular  cells,"  ''inflammation  globules,"  etc.,  are  aggre- 
gations of  minute  oil-globules  in  a  cell  form.' 

"  It  will  be  seen  by  this  extract  that  Beale  distinguishes  the  '  small, 
delicate,  transparent,  and  faintly  granular  cells'  from  the  compound 
granule-cells  or  corpuscles  of  Gluge.  The  description  which  he  gives 
of  the  first  cell,  with  the  exception  of  the  cell  heing  faintly  granular, 
corresponds  very  closely  with  that  of  the  ovarian  cell,  but  it  is  incom- 
plete, and  no  test  is  given  to  distinguish  this  from  other  granular 
cells."* 

I  do  not  think  he  mentions  with  as  much  distinctness  and  empha- 
sis as  it  deserves  the  abundant,  free,  granular  matter  floating  about 
in  connection  with  the  cells.  In  my  observations  this  granular  ma- 
terial, having  the  precise  appearance  of  the  granules  in  the  cells,  was 
the  most  striking  of  the  microscopic  appearances. 

The  chemical  nature  of  this  fluid  is  more  constant.  It  is  alkaline 
in  reaction  and  highly  albuminous,  always  coagulating  when  boiled 
or  submitted  to  the  action  of  strong  acids. 

Differential  Diagnosis. 

After  having  passed  in  review,  as  above,  the  items  of  general  diag- 
nosis of  ovarian  tumors,  I  propose  to  enter  upon  a  differential  view 
of  the  subject,  because  there  are  conditions  of  disease  and  health  of 
the  contents  of  the  female  pelvis  and  abdomen  for  which  they  may 
be  mistaken.  The  following  long  list  of  conditions  may  be  given 
as  likely  to  be  mistaken  for  ovarian  tumor :  1st.  Retroversion  and 
retroflexion.  2d.  Tumors  of  the  uterus, — solid,  fibrous,  or  fibro- 
cystic, od.  Pregnancy.  4th.  Pregnancy  complicating  ovarian  dropsy. 
5th.  Cystic  tumors  of  the  abdomen.  6th.  Distended  bladder.  7th, 
Accumulation  of  gas  in  the  intestines.  8th.  Accumulation  of  faeces  in 
the  intestines.  9th.  Enlargement  of  the  liver,  spleen,  or  kidneys,  or 
tumors  connected  with  the  viscera.  10th.  Rectovaginal  hernia  and 
displacement  of  the  ovary.  11th,  Pelvic  abscess.  12th.  Retention  of 
menstrual  fluid  from  imperforate  hymen  or  closure  of  the  os  uteri, 
13th.  Hydrometra,  14th,  Accumulation  of  fat  in  the  abdominal 
walls.  15th,  Accretions  in  the  subperitoneal  connective  tissue,  or  in 
the  peritoneal  cavity. 

In  cases  of  retroversion  or  retroflexion,  if  minute  examination  with 
the  finger  per  vaginam  and  rectum  fail,  and  the  symptoms  are  of  a 
character  to  make  a  correct  diagnosis  important,  the  uterine  probe 

*  Thomas  M.  Drysdale,  M.D.,  PJiiladelphia,  in  the  Transactions  of  the  American 
Medical  Association,  1873. 


724  OVARIAN   TUMORS. 

will  at  once  determine  the  distinction.  In  some  instances  we  might 
be  quite  unable  to  distinguish  a  small  ovarian  tumor  from  an  impreg- 
nated retroverted  uterus.  Our  proper  plan  in  such  cases  is  to  await 
the  peremptory  demand  for  the  knowledge,  and  then  take  the  risk  of 
introducing  the  probe,  remembering  the  position  of  the  mouth  of  the 
womb  in  retroversion,  that  it  is  not  only  near  the  ]3ubis,  but  directed 
upwards  as  well  as  forwards,  and  that  the  os,  in  cases  of  misplace- 
ment by  the  tumor,  is  not  directed  upward,  but  nearly  always  down- 
ward,—  certainly  never,  so  far  as  my  experience  and  reading  go, 
above  the  horizontal  position.  The  probe  may  be  equally  available 
in  examining  the  retroflexed  organ,  and  I  think  the  probe  should 
always  be  used  where  pregnancy  is  not  suspected.  Should  we  feel 
much  doubt  of  the  existence  of  pregnancy  in  connection  with  retro- 
version, it  would  be  better  to  lift  the  tumor  out  of  the  pelvis ;  when, 
if  it  were  retroversion,  the  uterus  would  be  restored  to  its  natural 
position,  with  the  os  near  the  centre  of  the  pelvis.  In  endeavoring 
to  distinguish  between  ovarian  and  uterine  tumors,  we  should  bear 
in  mind  that  the  latter  almost  invariably  change  the  length  and  size 
of  the  cavity  of  the  uterus.  Where  the  sound  is  used,  it  will  pass 
further  than  if  the  uterus  was  not  involved.  The  rationale  of  this 
increase  of  size  of  the  uterus,  so  generally  found  to  be  present,  is  con- 
nected with  the  fact  that  the  development  of  a  tumor  in  or  from  the 
walls  of  that  organ  induces  general  hypertrojjhy  to  some  extent,  as 
these  growths  are  found  to  be  a  hypertrophy  of  some  one  of  the 
uterine  tissues.  The  tissues  generally  involved  are  the  fibrous  or 
mucous,  as  in  hard  or  soft  polypi  from  the  internal,  or  hard  from 
the  external  walls,  or  intramural  fibrous  tumors.  Uterine  tumors 
are  so  intimately  connected  with  the  uterus  that  this  organ  cannot  be 
moved  without  imparting  more  or  less  motion  to  the  tumor,  nor  can 
the  tumor,  on  the  other  hand,  be  moved  without,  in  a  similar  way, 
affecting  that  organ.  This  is  not  the  case  with  ovarian  tumors. 
They  are  so  loosely  connected  with  the  womb  that  considerable 
motion  is  allowable  without  the  other  partaking  of  it.  In  the  sound 
we  have  the  means  of  moving  or  fixing  the  uterus,  and  with  the 
finger  may  watch  the  effect  of  motion  upon  the  one  or  the  other,  as 
the  case  maybe.  When  the  fibro-cystic  tumor  is  developed  upon  the 
uterus,  containing  fluid,  the  examination  to  ascertain  whether  there  is 
an  attachment  with  the  uterus,  and  with  a  view  to  learn  the  length 
of  the  cavity,  will  give  us  clear  notions  of  the  matter.  When  we  are 
satisfied  that  i^regnancy  cannot  be  the  condition,  we  may  explore  or 
tap  it  as  an  additional  means  of  accuracy. 

Hard  or  fluid  tumors  arising  from  a  distant  organ  or  part  of  the 
abdomen  Avould  have  a  different  history  from  the  ovarian  tumor.  If 
our  patient  is  intelligent,  her  observation  as  to  the  place  where  first 


DIFFERENTIAL    DIAGNOSIS.  725 

noticed  should  be  relied  upon  as  valuable  knowledge  respecting  the 
probable  point  of  origin. 

Ascites,  when  excessive,  may  sometimes  be  mistaken  for  ovarian 
tumor,  but  the  latter  is  more  frequently  taken  for  the  former.  When 
the  patient  lies  on  her  back,  with  the  knees  drawn  up,  so  as  much  as 
possible  to  relax  the  muscles,  and  the  abdomen  is  entirely  exposed,  in 
ascites  the  tumidity  will  be  rotund,  filling  out  in  every  direction,  and 
will  particularly  bulge  the  depending  portions.  The  flanks  will  both 
be  full ;  the  abdominal  protrusion  commences  at  the  edges  of  the 
ribs,  and  will  be  equally  soft  at  every  point;  fluctuation  will  be 
greatest  at  the  most  dependent  parts,  and  resonance  entirely  absent; 
fluctuation  will  scarcely  be  perceptible  in  the  highest  part  of  the  ab- 
domen, but  there  will  be  resonance  there.  These  circumstances  will 
remain  the  same  under  any  change  of  position.  If  the  patient  stand 
up  the  dulness  is  in  the  hypogastric  and  iliac  regions.  If  she  lie  on 
her  side,  the  dulness  and  fluctuation  on  the  lower  side ;  resonance  on 
the  upper  side.  All  this  results  from  the  water  freely  settling  into 
the  lowest  points,  let  them  be  what  they  may.  In  ovarian  tumor, 
alteration  of  position  from  erect  to  recumbent,  or  from  supine  to 
prone,  makes  no  difference  in  the  places  where  resonance  and  fluctua- 
tion are  found.  They  are  manifested  always  in  the  same  places. 
When  the  patient  lies  on  the  back,  the  flanks  are  resonant,  the  um- 
bilical region  dull.  Fluctuation  is  not  observed  in  the  flank  in  any 
position ;  it  is  apt  to  be  greatest  under  any  posture  in  the  middle  of 
the  abdomen.  When  the  abdomen  is  exposed  for  inspection  there  is 
marked  irregularity  in  its  rotundity,  and  I  think,  ordinarily,  the  flanks, 
one  or  both,  are  flat.  One  side  is  apt  to  bulge  more  than  the  other. 
Probably  there  is  more  than  one  rather  prominent  region, — it  may  be 
several.  There  is  more  hardness  and  tension  ;  not  the  flabby  swaying 
under  slight  influences,  so  common  as  ascites.  Important  circum- 
stances in  the  pathological  condition  are  almost  always  present  in 
ascites.  It  seldom  occurs  in  persons  in  the  enjoyment  of  good  health 
in  every  other  respect.  There  is  organic  disease  of  the  kidneys,  liver, 
spleen,  heart,  lungs,  or  subacute  peritonitis.  Or  there  may  be  some 
cachexia  from  miasma,  poison,  or  other  bad  influence  of  particular 
places  of  residence,  occupation,  habits  or  time  of  life,  etc.  There  is 
some  notable  and  grave  pathological  accompaniment  of  abdominal 
dropsy  which  precedes  the  swelling ;  whereas  the  ill-health  in  ovarian 
dropsy  is  the  effect  and  not  the  cause.  We  generally  find  that  women 
preserve  a  good  condition  of  health  in  ovarian  disease  until  far  ad- 
vanced, and  disordered  functians  come  almost  always  as  the  result  of 
great  presteure  upon  the  suffering  organ.  A  complication  of  ascites 
with  ovarian  dropsy  obscures  our  diagnosis  very  much.  If  the  ascites 
is  great,  and  the  ovarian  disease  not  so  considerable,  the  tumor  will  be 
felt  floating  about,  as  it  were,  in  the  abundant  fluid,  when  the  patient 


726  OVAEIAN   TUMORS. 

changes  position.  Excluding  by  our  diagnostic  examination  every 
other  disease,  and  leaving  the  question  between  them  alone,  we  are 
justified  in  exploration  and  tapping.  By  the  former,  we  come  in  pos- 
session of  a  specimen  fluid,  which,  when  submitted  to  chemical  and 
microscopical  investigation,  is  almost  conclusive.  By  the  latter,  we 
partially  empty  the  abdominal  cavity  and  relax  the  walls  so  that  we 
can  examine  its  contents  with  great  freedom.  If  the  fluid  be  ovarian, 
it  will  be  highly  albuminous,  and  possess  the  microscopical  qualities  I 
have  before  mentioned.  If  it  be  ascitic,  the  properties  will  be  those  of 
serum  found  exuded  anywhere  from  pressure  or  inflammation.  There 
will  be  very  little,  if  any,  albumen,  no  epithelial  cells,  and  none  of  the 
corpuscles  described  by  Drysdale. 

It  will  occur  very  seldom  that  the  question  between  pregnancy  and 
ovarian  disease  will  become  so  urgent  that  it  may  not  safely  be  left  to 
time.  I  can  conceive  no  time  or  circumstance  under  which  great  doubt 
as  to  which  of  these  two  conditions  were  present  but  in  the  early  stages 
of  either,  while  in  the  pelvic  cavitj'' ;  and  unless  great  pressure  on  the 
organs  contained  in  it  make  delay  hazardous,  we  should  not  interfere, 
but  content  ourselves  to  wait  until  the  obvious  evidences,  as  quicken- 
ing and  motions  of  the  child,  declare  the  existence  of  pregnancy,  or 
until  so  much  time  has  elapsed  without  any  such  signs  as  to  throw 
great  doubt  upon  the  subject.  At  such  times  the  tumor  is  high  above 
the  pelvis,  and  may  be  subjected  to  any  searching  examination  we 
may  choose.  Auscultation  then  becomes  valuable  and  perfectly  re- 
liable, when  properly  practiced,  in  determining  the  presence  of  normal 
pregnancy. 

Frequent  examinations  with  the  stethoseoj)e  or  ear,  in  various  posi- 
tions, should  be  patiently  and  perseveringly  practiced  before  we  should 
be  satisfied  to  risk  means  of  a  hazardous  nature  that  will  enable  us 
positively  to  decide  the  question.  After  having  repeatedly  thus  ex- 
plored the  abdomen  without  any  sign  of  a  live  foetus,  we  may  use  the 
probe  to  examine  the  whereabouts  and  size  of  the  uterus.  No  mistake 
will  survive  the  test  of  this  instrument.  If  I  w^ere  not  to  explain 
myself  a  little  more  upon  this  point,  I  might  incur  the  charge  of  rash- 
ness for  recommending  the  sound  where  any  doubts  exist.  It  would 
be  rash  to  use  the  sound  until  all  the  differential  signs  of  pregnancy 
had  failed,  and  even  then,  unless  the  urgent  demand  caused  by  the 
influence  upon  the  health  forbids  us  to  wait  longer  for  a  decision.  It 
is  only  in  extreme  cases,  where  the  symptoms  and  signs  derived  from 
the  breasts,  condition  of  the  cervix,  menstruation,  nausea,  pigmentary 
deposits,  and  auscultation,  had  all  failed,  and  yet  I  was  obliged  to  act 
at  once  for  the  safety  of  the  patient,  that  I  should  consent  to  use  the 
sound.  Then  I  would  use  it  as  the  more  innocent  of  the  demonstra- 
tive tests,  and  as  a  dernier  ressort.  It  is  certainly  more  innocent  than 
the  exploring  needle  or  the  evacuating  trocar,  and  equally  demonstra- 


DIFFERENTIAL    DIAGNOSIS.  727 

'tive.  The  worst  effects  its  careful  use  could  have  would  be  to  produce 
abortion  or  premature  birth,  either  of  which  would  be  more  likely  to 
remove  the  urgency  of  the  symptoms  than  do  harm.  I  have  recently 
seen  an  instance  of  the  obscurity  of  diagnosis,  from  the  existence  of 
a  pregnancy  of  eight  and  a  half  months'  duration,  decided  by  the 
probe,,  which  caused  the  discharge  of  a  mummified  foetus  of  less  than 
four  months'  growth,  and,  as  a  matter  of  course,  almost  cured  the 
patient. 

Pregnancy  complicated  with  ovarian  dropsy,  may  be  very  perplex- 
ing to  diagnosticate.  Mistakes  of  diagnosis  have  occurred  in  the 
hands  of  Sims,  Wells,  the  author,  and  others.  A  careful  examination 
of  the  cervix  uteri,  the  abdomen,  breasts,  etc.,  for  the  evidence  of  preg- 
nancy above  mentioned,  will  seldom  fail  to  make  a  diagnosis  of  this 
complication  clear.  There  are  very  few  collections  or  growths  that  can 
be,  in  sach  conditions,  mistaken  for  this. 

In  pelvic  abscess,  there  will  be  inflammatory  tenderness  and  heat. 
The  most  likely  of  all  others,  is  a  prolapsed  bladder.  Our  diagnosis, 
however,  will  be  easily  effected  by  using  the  catheter,  when,  if  it  is 
the  bladder,  emptying  causes  its  collapse  and  the  entire  disappear- 
ance of  the  tumor.  But  if,  after  the  complete  evacuation  of  the 
bladder,  there  is  yet  a  tumor  containing  fluid,  exploration  should  be 
resorted  to.  This  will  clear  up  the  diagnosis,  provided  the  exploring 
trocar  is  large  enough  to  evacuate  a  part  or  the  whole  of  its  contents. 
There  are  other  fluid  tumors,  arising  from  the  broad  ligaments  near 
the  ovary,  probably  dependent  upon  a  great  increase  of  one  or  more 
of  those  transparent  cells  of  serum,  so  generally  seen  by  looking 
through  this  peritoneal  duplicature,  towards  the  light.  These  may  be 
mistaken  for  actual  ovarian  cysts,  and  are  doubtless  the  cases  of 
ovarian  disease  that  are  permanently  cured  by  a  single  tapping.  No 
means  of  diagnosis  now  known  would  enable  us  to  decide,  with  any 
certainty,  between  the  two  except  chemical  and  microscopic  exam- 
ination of  the  fluid.  The  fluid  is  a  limpid  serum  of  very  low  specific 
gravity,  sometimes  not  above  that  of  distilled  water,  often  not  more 
than  1004,  not  coagulable  by  heat  and  devoid  of  any  microscopic 
peculiarity.  It  has  a  remarkable  semblance  in  most  of  its  qualities 
to  pure  water.  Cystic  tumors  of  the  abdomen,  arising  from  other 
points,  and  hydatids  of  the  peritoneal  cavity,  can  be  distinguished 
with  certainty  in  no  way  except  by  exploration  and  examination  of 
the  contents.  The  history  will,  if  carefully  and  intelligently  detailed, 
show  something,  perhaps,  that  we  may  seize  upon  to  aid  us.  The 
case  should  commence,  if  ovarian,  in  a  tumor  arising  from  the  pelvis, 
gradually  ascending  into  the  abdomen.  If  abdominal,  it  is  first 
noticed  in  that  cavity,  and  may  descend  until  it  occupies  all  the  ab- 
domen, and  then  the  pelvis  also.  If  hydatid,  the  increase  is  mere 
tumidity,  not  a  well-defined  tumor,  and  it  commences  in  the  abdomen. 


728  •    OVAEIAX   TUMORS. 

The  distended  bladder,  accumulation  of  gas  in  the  intestines,  or 
of  faeces,  ought  not,  in  the  present  state  of  our  science,  to  embarrass 
us  any  longer  than  the  catheter  or  a  cathartic  could  be  brought  to 
bear  upon  the  case.  As  soon  as  the  bladder  is  emptied  it  will  col- 
lapse. The  gas  in  the  bowels  causes  tympanites  of  the  abdomen, 
and  thus  ought  to  be  detected.  The  accumulation  of  faeces  .can  be 
removed,  when  the  tumor  will  be  gone.  Hysterical  distension  of  the 
abdomen,  said  to  simulate  pregnancy,  ovarian,  uterine,  and  other 
tumors,  entirely  disappears  under  the  influence  of  chloroform,  as 
shown  by  Professor  Simpson,  on  many  occasions. 

Visceral  enlargement,  as  liver,  spleen,  kidneys,  and  tumors  growing 
from  them,  are  not  unfrequently  mistaken  for  these  tumors.  I  have 
a  patient  now  laboring  under  enlargement  of  the  spleen,  who  has 
been  told  more  than  once,  that  she  had  ovarian  disease.  Unless 
the  enlargement  of  the  liver  or  spleen  is  excessive,  I  cannot  see  how 
a  mistake  can  be  possible.  The  history  as  to  where  the  tumor  was 
first  observed  should  be  carefully  traced.  If  either  of  these,  it  has  . 
descended.  I  have  not  seen  a  liver  or  spleen  occupying  the  cavity  of 
the  abdomen  so  completely,  but  that  its  well-defined  edge  could  be 
felt  for  a  considerable  distance,  and  this  edge  is  always  below,  while 
the  upper  boundary  is  less  defined  or  traceable  beneath  the  ribs.  I 
have  on  several  occasions,  seen  the  spleen  enlarged  and  dislocated, 
occupying  the  left  iliac  region,  and  reaching  up  towards  the  hypo- 
chondriac, but  there  are  always  sharp  edges  somewhere.  This  is  not 
the  case  in  ovarian  dropsy ;  it  is  round,  somewhat  even,  and  elastic 
to  the  touch. 

The  liver  is  also  sometimes  displaced  to  such  an  extent  as  to  rest 
upon  the  pelvic  brim ;  and,  when  enlarged,  it  may  occupy  an  exten- 
sive space  in  the  abdomen.  The  three  important  points  to  be  made 
in  the  differential  diagnosis  between  displacements  and  enlargement 
of  the  liver  and  spleen  and  ovarian  tumors  are :  1st,  they  are  flat  in 
front,  instead  of  globular;  2d,  by  somewhat  forcible  percussion  even 
very  decided  intestinal  resonance  may  be  heard  through  them;  3d, 
by  well-directed  manipulation  in  the  horizontal  position  the  displaced 
organ  may  be  partially  or  completely  returned  to  its  natural  nidus. 

Mr.  Brown  mentions  recto-vaginal  hernia  and  dislocation  of  the 
ovary  into  the  cul-de-sac  of  Douglas.  The  diagnosis  would  be  diffi- 
cult and  unimportant  unless  in  exceptional  cases.  The  great  impor- 
tance of  a  correct  diagnosis  is  based  upon  the  urgent  symptoms  and 
fatal  tendency  of  the  disease. 

Retention  of  menstrual  fluid  from  imperforate  hymen  (or  other 
obstruction  to  its  outlet),  also  hydrometra,  as  soon  as  we  have  by 
physical  examination,  history,  and  the  rational  symptoms,  decided 
that  the  patient  is  not  pregnant,  the  finger  and  sound  will  clear  up  all 


DIFFERENTIAL    DIAGNOSIS.  729 

doubts  in  a  short  time.     Obstructions  will  be  ascertained  or  overcome 
by  them,  and  our  misgiving  dispelled. 

Acute,  and  sometimes  even  subacute,  inflammation  of  the  peri- 
toneum is  occasionally  accompanied  and  succeeded  by  hard,  fibrinous 
deposits  of  various  sizes  and  location  in  the  abdomen.  When  in  the 
iliac  and  hypogastric  regions  they  may  be  mistaken  for  tumors.  They 
are  flat,  immovable,  sensitive  ;  yield  resonance  in  a  very  decided  man- 
ner upon  percussion,  and  date  their  existence  from  an  attack,  more  or 
less  remote,  of  peritoneal  inflammation. 

Supposing  our  diagnosis  complete  as  to  its  being  an  ovarian  tumor, 
we  have  yet  to  learn,  for  the  more  intelligent  treatment,  several  other 
things ;  among  these  are :  What  are  the  contents  and  construction  of 
it?  Is  it  monocystic  or  polycystic?  Are  its  contents  partly  solid,  or 
wholly  fluid?  Although,  probably,  not  always  possible  to  decide 
these  questions  without  exploratory  operations,  we  have  some  means 
of  clearing  them  up.  A  diligent  and  careful  examination  by  percus- 
sion and  inspection  will  enable  us  to  judge  correctly,  in  most  cases, 
whether  the  tumor  is  monocystic  or  polycystic,  or  otherwise.  If  mono- 
cystic,  the  tumor  is  regular  in  its  rotundity  and  outline ;  if  polycystic, 
there  is  some  inregularity  of  elevation,  made  out  best  by  sliding  the 
hand  over  the  surface.  Fluctuation,  caused  by  percussion,  is  the  same 
in  all  directions  and  from  all  points  of  it  in  monocystic.  In  poly- 
cystic it  is  very  obscure,  except  over  partial  measurements.  The 
fingers  placed  near  each  other  over  the  same  cyst  feel  the  fluctuation 
very  sensibly ;  but  when  one  is  removed  so  as  to  pass  over  the  parti- 
tion between  it  and  the  next  cyst,  the  fluctuation  becomes  more  ob- 
scure. By  examining  all  parts  with  both  hands,  separating  and 
approximating  each  other,  we  make  out  the  dimensions  and  situation 
of  the  cyst,  which  lies  in  contact  with  the  abdominal  walls.  The 
fluctuation,  or  its  absence,  will  determine  whether  a  given  part  of  the 
tumor  is  solid  or  fluid.  The  hard  parts  of  an  ovarian  tumor  are, 
almost  invariably,  at  the  bottom  of  the  tumor,  and  may  be  reached 
by  the  finger  per  vaginam.  While  our  fingers  are  in  contact  with  the 
base  of  the  tumor  in  the  pelvis,  if  it  is  wholly  fluid,  we  may  feel  fluc=- 
tuation,  if  the  top  of  the  tumor  is  struck  with  the  other  hand.  If  a 
solid  part  intervenes  between  our  two  hands,  fluctuation  would  not  be 
experienced. 


CHAPTEE   XLIII. 

OVARIAN  TUMORS  {Continued ). 

Treatment. 

It  is  not  necessary  to  interfere,  in  any  manner,  with  some  cases  of 
ovarian  dropsy.  There  are  many  instances  which  advance  slowly,  or 
remain  stationary  for  a  great  many  years,  and  prove  but  an  incon- 
venience. We  would  not  be  justified  in  active  interference  in  these; 
much  less  should  we  do  anything  directly  for  cases  in  which  indepen- 
dent complications  of  a  fatal  character  exist,  e.  g.,  phthisis  or  cancer, 
albuminuria,  etc.  When,  however,  the  disease  is  making  obvious 
progress,  and  particularly  when  the  advance  is  sufficiently  rapid  to 
leave  but  little  doubt  of  its  proving  fatal  within  the  average  time  of 
their  duration,  we  are  bound  to  make  every  effort  within  our  power  to 
save  or  prolong,  as  much  as  possible,  the  life  of  our  patient. 

The  treatment  of  ovarian  tumors  may  be  divided  into  palliative  and 
.curative.  The  one  intended  to  relieve,  as  far  as  possible,  the  suffer- 
ings of  the  patient  under  the  disease,  or  to  retard  the  rapidity  of  its 
progress  ;  the  other  to  remove  or  destroy  the  tumor,  and  thus  do  away 
with  the  cause  of  the  evil  entirely. 

When  doubt  exists  as  to  the  propriety  of  instituting  radical  treat- 
ment, we  should  continue  to  pursue  the  palliative  until  that  doubt  is 
dispelled.  There  are  three  sorts  of  cases  to  which  the  palliative  is 
indisputably  adapted.  They  are,  first,  those  in  which,  while  there 
is  a  steady  advance,  in  consequence  of  the  absence  and  probable 
remoteness  of  urgent  symptoms,  it  is  not  desirable  to  use  radical 
means.  The  second  class  of  cases  is  that  in  which  the  symptoms  are 
urgent,  but  in. which  it  is  not  desirable  to  use  radical  means  in  con- 
sequence of  the  slight  chances  of  success.  The  third  are  such  as,  in 
their  nature  and  condition,  would  call  for  curative  means,  but  the 
patient  will  not  consent  to  their  employment  from  fear  of  the  danger 
or  pain  they  inflict.  The  first  set  of  cases  is  not  very  frequentl}''  met 
with  compared  to  either  of  the  others ;  yet  we  do  occasionally  meet 
with  these  slowly  marching  cases,  in  which  we  have  an  opportunity 
to  try  the  effect  of  medicines ;  and  it  is  precisel}^  in  this  kind  of  cases 
that  we  appear  to  derive  most  benefit  from  medicines  internally  ad- 
ministered. We  are  apt  to  believe  that  the  tardy  development  is 
dependent  upon  the  virtue  of  some  favorite  remedy  used,  and  deceive 
ourselves  as  to  its  efficienc}^  when  really  all  depends  on  the  natural 
slowness  of  the  tumor.     The  alteratives,  as  mercury,  iodine,  sarsapa- 


TEEATMENT.  731 

rilla,  chlorine,  etc.,  have  all  had  their  advocates.  It  was  at  one  time, 
and  even  now  is,  the  practice  of  some  men  of  ability  to  give  mercury 
to  very  slight  ptyalism,  with  the  hope  of  bringing  about  absorption. 
Iodine,  administered  frequently,  so  as  to  induce  its  specific  influence 
upon  the  organism,  has  been,  and  is  still,  by  some  highly  lauded  as 
capable  of  curing  ovarian  dropsy.  A  chronic  administration  of  either 
of  these  remedies  is  sure  to  affect  unfavorably  the  general  health  ; 
and,  as  it  is  extremely  doubtful  whether  there  is  any  efficacy  in  them, 
we  should  not  be  too  profuse  in  their  use.  Effusion  into  the  perito- 
neal sac,  or  subacute  inflammatory  complications,  are  often  very  much 
benefited  by  a  moderately  protracted  course  of  these  remedies.  For 
the  same  purpose,  local  depletion,  counter-irritants,  such  as  iodine 
ointment,  strong  enough  to  induce  irritation  of  the  skin,  are  often  use- 
ful; so  are  diaphoretics,  diuretics,  and  cathartics.  In  the  second 
class  of  cases  we  need  not  feel  so  restricted  in  our  efforts  at  palliation. 
It  is  best,  however,  to  bear  in  mind  that  too  great  activity  of  medi- 
cation will  often  do  more  harm  than  good.  Our  object  should  be  to 
promote  such  functions  as  are  obstructed  or  restricted;  the  kidneys, 
for  instance,  need  especial  attention,  as  also  the  intestinal  canal.  The 
acids  have  always  seemed  to  me  to  be  particularly  applicable  to  these 
cases.  The  nitric,  nitro-muriatic,  sulphuric,  phosphoric,  acetic,  are 
all  useful,  and  may  be  alternated  often  with  the  hope  of  relieving 
the  distressing  indigestion  attendant  upon  great  distension  and  im- 
perfect performance  of  the  renal  functions.  They  also  very  much 
moderate  the  distressing  exudations  from  the  skin,  which  are  often 
present.  The  chlorinated  tincture  of  iron  is  also  an  excellent  tonic. 
These  remedies  may  very  properly  be  administered  in  some  of  the 
bitter  infusions,- — quassia,  chamomile,  wild-cherry  bark,  etc.  The 
best  time  to  give  them  is  immediately  after  eating.  Stimulants  ought 
not  to  be  too  freely  used,  as  they  encourage  the  establishment  of  com- 
plications. Brandy  I  think  the  best  of  tbe  stimulants,  and  it  should 
be  given  more  for  the  purpose  of  inducing  sleej)  than  anything  els"e ; 
and  this  it  will  often  do  when  taken  in  a  sufficient  dose  on  an  empty 
stomach  at  bedtime.  When  great  restlessness  and  want  of  sleep  are 
Avearing  out  the  patient,  we  must,  as  in  all  similar  circumstances  in 
other  diseases,  resort  to  the  assortment  of  anodynes,  beginning  with 
the  less  disturbing,  being  sure  to  be  under  the  necessity  of  ending 
with  opium.  Chloroform,  internally  administered,  is,  I  am  confident, 
not  sufficiently  relied  ui:)on.  Teaspoonful  doses,  given  in  milk,  will 
seldom  fail  to  induce  a  fine  anodyne  effect.  There  is  greater  neces- 
sity, perhaps,  for  a  gradual  increase  of  the  dose  in  using  it  than 
opium,  or  most  other  efficient  anodynes.  Hyoscyamus,  belladonna, 
cicuta,  should  be  all  tried  before  opium. 

We  must  be  on  the  alert   for  complications,  and  ready  for  their 
appropriate   treatment.     The    distressing    constipation,   which   often 


732  OVARIAN    TUMOES. 

annoys  the  patient  and  physician,  will  demand  a  great  share  of  our 
attention.  Injections  of  water  and  various  substances  wall,  of  course, 
suggest  themselves.  It  has  occurred  to  me  to  be  able  to  induce  free 
movements  of  the  bowels  by  having  a  pint  of  warm  lard  thrown  high 
up  in  the  bowels  when  they  are  very  obstinate ;  the  longer  the  lard 
is  retained  the  better.  This,  administered  once  a  day,  will  act  excel- 
lently well  sometimes.  An  ounce  of  fresh  beef's  gall,  with  three 
or  four  ounces  of  water,  often  does  as  well.  But  the  time  comes, 
sooner  or  later,  with  the  steadily  increasing  pressure  of  the  tumor, 
when  to  lessen  its  size  is  indispensable  to  the  further  extension  of 
life. 

Tapping  suggests  itself  as  the  only  surgical  palliative  in  this  state 
of  things.  This  operation  is  more  beneficial  in  unilocular  tumors 
than  in  any  other  sort,  but  is  applicable  as  a  palliative  measure,  in 
any  tumor  containing  fluid,  when  demanded  by  the  supervention  of 
urgent  symptoms  indicating  the  necessity  of  immediate  relief.  Under 
the  desperate  circumstances  mentioned,  there  can  be  no  question  about 
the  propriety  of  tapping  the  patient;  yet  this  apparently  trifling 
operation  is  not  devoid  of  inconveniences  and  dangers  that  should  be 
weighed  deliberately,  and  if  they  do  not  deter  us  from  resorting  to 
it,  will  at  least  make  us  particular  not  to  use  it  as  anything  but  an 
indispensable  remedy.  One  serious  inconvenience  connected  with 
tapping  is  the  readiness  with  which  the  fluid  accumulates  in  the  sac. 

The  clangers  of  tapping  are  both  immediate  and  remote.  The 
immediate  are  such  as  are  connected  with,  and  occur  immediately 
upon,  the  performance  of  the  operation.  Dr.  Simpson  sums  up  five 
that  are  more  frequent,  and  against  which  we  should  be  upon  our 
guard.  First,  the  chance  of  wounding  the  urinary  bladder.  This 
may  be  avoided  by  evacuating  the  organ,  unless  it  is  tied  to  the  ab- 
dominal wall  by  adhesions,  which  we  can  ascertain  by  introducing 
the  sound.  Second,  the  puncture  of  the  uterus  when  it  is  draAvn  up 
with  the  tumor.  By  introducing  the  sound  into  its  cavity  we  may 
learn  its  whereabouts,  and  thus  be  enabled  to  avoid  it.  Third,  the 
front  part  of  the  tumor  may  be  traversed  by  the  Fallopian  tube,  and 
this  last  be  wounded  by  the  trocar.  Fourth,  the  internal  venous  cir- 
culation, on  account  of  the  pressure,  is  obstructed  sometimes,  and  the 
blood  is  directed  to  the  veins  in  the  walls  of  the  abdomen  or  tissue, 
so  that  these  veins  may  be  wounded ;  but  generally  they  are  large 
and  may  be  seen,  and  thus  avoided.  Fifth,  the  epigastric  artery  is 
sometimes  wounded.  We  should  carefully  feel  for  the  pulsation  of 
arteries  in  the  thin  walls  before  the  trocar  is  plunged  into  the  tumor. 
As  may  be  seen,  these  dangers  may,  for  the  most  part,  be  provided 
against;  but  the  second  class  of  dangers,  namely,  the  remote, — those 
that  follow  some  time  after  the  operation,  and  are  not  dependent  on 
the  manner  or  place  of  the  puncture, — are  not  so  easily  avoided. 


TREATMENT.  733 

The  dangers  and  benefits  of  tapping  cannot,  and  ought  not,  to  be 
estimated  by  comparison  with  other  operations.  Each  operation,  of 
Avhatever  kind,  has  its  place,  and  is  followed  by  its  good  or  bad  effects, 
for  the  reason,  among  others,  that  it  is  appropriate,  or  inappropriate. 
Generally,  no  two  operations  are  applicable  to  any  one  condition  of 
things ;  and  we  should  not  allow  the  question  of  danger  to  decide  be- 
tween them,  unless  in  very  rare  and  exceptional  cases.  The  statistics, 
as  far  as  1  have  been  able  to  collect  them,  may  be  well  summed  up,  as 
Dr.  West  has  done,  and  I  shall  rely  upon  his  figures : 

"The  chief,  indeed,  almost  the  only  numerical  data  of  which  we  are  possessed,  bear- 
ing on  this  subject,  are  derived  from  a  table  of  20  cases,  compiled  by  Mr.  Southam  ;  of 
45  cases  collected  by  the  late  Mr.  Lee;  and  of  64,  the  results  of  which  are  given  by 
Professor  Kiwisch.  Of  these  130  cases,  22  terminated  fatally  within  a  few  hours  or 
days  after  tapping,  and  25  more  in  the  following  six  months ;  or,  in  other  words,  34.7 
per  cent,  of  the  cases  ended  in  the  patient's  death  in  the  course  of  half  a  year  after  the 
performance  of  tapping.  In  114  of  the  130  death  is  stated  to  have  taken  place:  22 
within  less  than  ten  days,  25  within  six  months,  2.  within  one  year,  21  within  two 
years,  11  within  three  years,  13  after  a  period  exceeding  three,  and  in  some  amount- 
ing to  several  years. 

"In  109  of  these  cases,  we  are  further  informed  how  often  the  patients  had  been 
tapped.  It  appears  that  46  died  after  the  first  tapping,  10  after  the  second,  25  after 
from  three  to  six  tappings,  15  after  seven  to  twelve,  13  after  more  than  twelve." 

It  would  appear  that  the  first  tapping  is  very  much  more  dangerous 
,than  subsequent  ones.     Dr.  West  says  further: 

"Unfavorable,  however,  as  are  the  conclusions  to  which  we  are  irresistibly  led  by 
such  facts  as  those  which  have  just  been  mentioned  with  reference  to  the  ultimate 
issue  of  tapping,  it  is  yet  very  questionable  whether  they  represent  the  whole  of  the 
truth  concerning  this  matter." 

Dr.  Atlee,  of  Philadelphia,  thinks  tapping  not  a  very  dangerous 
operation.     Mr.  Brown  thinks  its  clangers  greatly  overrated. 

There  can  be  but  little  doubt  that  much  of  the  mortality  of  tapping 
is  due  to  the  fact  of  the  desperate  character  of  the  cases  in  which  it  is 
used;  and  the  reason  why  so  many  die  in  so  short  a  time  after  the 
first  operation  is,  that  in  many  instances  the  patient  is  almost  mori- 
bund before  it  is  resorted  to.  When  not  attended  with  the  imme- 
diate dangers  above  enumerated,  tapping  is  either  followed  by  great 
relief  from  suffering  or  by  the  remote  or  sequential  dangers.  They 
are,  for  the  most  part,  prostration  or  inflammation.  The  prostration 
is  sometimes  so  great  that  no  management  can  prevent  the  patient 
from  dying  in  a  very  short  time.  Such  great  prostration  is,  how- 
ever, exceedingly  rare ;  it  is  more  common  to  have  it  in  a  more  mod- 
erate degree.  The  patient  will  feel  faint  for  an  hour  or  two,  and 
then  gradually  rally,  or  she  may  continue  to  be  pale  and  languid  for 


734  OVAEIAN   TUMORS. 

several  days.  For  such  slight  cases  the  horizontal  position,  rest,  and 
good,  digestible,  somewhat  stimulating  food,  is  all  that  will  be  needed. 
When  the  j)rostration  is  great,  and  danger  of  fatal  sinking  present, 
the  case  must  be  treated  energetically.  The  means  calculated  to 
bring  about  reaction  must  have  reference  to  the  causes  of  the  pros^ 
tration.  The  evacuation  from  the  general  vascular  system  is  not  a 
cause,  because  the  fluid  in  the  tumor  is  extravascular ;  but  it  is  a 
sudden  change  in  the  distribution  of  the  blood.  The  evacuation  of 
the  abdominal  cavity  of  so  large  a  bulk  of  its  contents,  and  the  in- 
ability of  the  abdominal  muscles  to  contract  sufficiently  to  keep  up 
the  pressure  to  which  the  viscera  have  been  habituated,  are  the 
causes  of  the  irregular  distribution  of  the  blood.  The  want  of  pres- 
sure upon  the  abdominal  viscera  allows  a  large  accumulation  of 
blood  in  the  veins,  and  it  is  there  retained.  In  proportion  to  the 
amount  thus  collected  in  the  abdomen,  will  the  blood  be  withdrawn 
from  other  parts  and  organs.  The  brain  will  partake  of  this  tempo- 
rary ansemia,  and  consequently  be  incapable  of  discharging  its  func- 
tions with  its  wonted  efficiency.  This  is  the  condition, — not  a  want, 
but  an  irregular  distribution  of  blood.  Our  first  object  should  be  to, 
as  nearly  as  possible,  re-establish  the  previous  condition  of  the  abdo- 
men. This  can  be,  to  some  extent,  accomplished  by  pressure,  with 
compresses  and  rollers.  The  compresses  should  be  as  large  as  the 
space  covered  by  the  muscles  of  the  abdomen,  and  thick  enough  to 
fill  up  much  above  the  level  of  the  ribs  and  iliac  bones  on  the  side. 
The  roller  should  be  applied  from  the  pubis  to  the  ensiform  cartilage, 
with  as  much  power  as  the  patient  can  bear  without  great  discomfort. 
Then  the  head  should  be  persistently  kept  below  the  level  of  the 
body.  This  simple  treatment,  instituted  early,  will  do  more  than  all 
other  means  without  it.  We  can  very  properly,  however,  give  stimu- 
lants, in  addition,  when  necessary.  When  this  danger  is  passed, 
inflammation  of  the  sac  or  peritoneal  cavity  is  next  to  be  appre- 
hended. The  sac  undergoes  every  degree  of  inflammation,  from  the 
slow,  subacute,  unobserved  degree,  which  vitiates  the  fluid  effused 
into  it,  either  by  causing  decomposition  in  it,  or  by  the  production  of 
pus,  or  effusion  of  blood  inside,  or  fibrin  on  the  external  surface — in 
this  last  case  causing  adhesion — or  such  degeneration  of. the  walls  of 
the  sac  as  to  cause  an  obliteration  of  the  cavity,  a  cessation  of  its 
secreting  powers,  or  a  perforation,  and  consequent  peritoneal  commu- 
nication ;  or,  what  is  perhaps  more  common,  an  acute  degree,  an- 
nounced by  severe  pain,  referred  to  the  point  most  intensely  affected, 
or  to  the  whole  abdominal  region,  thus  showing  the  probable  involve- 
ment of  the  peritoneum.  Indeed,  I  tbink  it  very  probable  that  the 
sharp  pain  ordinarily  present  in  these  cases,  indicates  peritoneal  in- 
flammation, and  that  there  is  but  little  pain  in  the  case  of  inflamma- 
tion of  the  fibrous  and  internal  coats  of  the  sac.     Fever,  of  a  some- 


TEEATMENT.  735 

what  high  grade,  is  apt  to  attend  upon  the  degree  of  inflammation  last 
mentioned,  accompanied  by  headache,  weariness,  aching  in  the  back, 
limbs,  etc.  But  in  the  inflammation  of  the  inner  coats,  in  which  pus 
or  fibrinous  products  are  eflfnsed  in  the  fluid  of  the  tumor,  there  is 
generally  but  slight  fever,  perhaps  none  at  first ;  but  the  vital  powers 
are  more  or  less  depressed,  copious  perspirations  at  night,  possibly  de- 
lirium, and  in  bad  cases,  all  the  symptoms  of  pyemia,  hectic  exhaus- 
tion and  death.  Now  all  morbid  conditions  resulting  from  tapping 
should  be  met  promptly  by  the  remedies  appropriate  to  them  when 
they  occur  under  other  circumstances, — antiphlogistic  regimen,  deple- 
tion, fomentations,  cathartics,  anodynes,  alteratives,  etc.  In  pyemia, 
tonics,  stimulants,  good  diet,  and  time  will  be  our  resort. 

The  operation  of  tapping  is  simple,  and  easily  performed  generally. 
To  avoid  the  depression  which  follows  the  evacuation  of  so  large  a 
quantity  of  fluid  as  is  contained  in  the  abdomen  sometimes,  we  should 
have  our  patient  on  the  side,  very  near  the  edge  of  the  bed,  with  her 
head  and  shoulders  low.  Two  large  and  long  hand-towels  should  be 
passed  around  her  body,  with  the  edges  close  together  upon  a  level 
with  the  point  where  we  wish  to  introduce  the  trocar,  and  these  ends 
given  to  an  assistant,  who  stands  behind  the  patient.  The  assistant 
having  in  charge  these  hand-towels  should  be  directed  to  draw  upon 
them  so  as  to  keep  up  a  state  of  tension  as  the  fluid  is  being  evacuated. 
To  avoid  the  dangers  enumerated  as  immediate,  we  should  assure  our- 
selves that  the  bladder  is  empty,  and  if  we  mistrust  that  it  is  not  in 
its  proper  place,  we  should  introduce  a  sound,  so  as  to  assure  ourselves 
of  the  whereabouts  of  the  fundus.  If  we  have  not  already  done  so, 
we  must  sound  the  uterus,  also,  and  thus  be  sure  of  its  harmless 
position.  After  these  precautions,  the  best  rule,  perhaps,  is  that  given 
by  the  late  Sir  James  Y.  Simpson,  and  that  is,  to  feel  for  the  most 
fluctuating  point,  the  place  where  the  walls  are  thinnest,  look  for  veins 
and  feel  for  the  pulsation  of  arteries.  The  thinnest  part,  where  fluc- 
tuation is  most  evident,  is  usually  the  right  place  to  make  the  punc- 
ture ;  but  there  is  not  always  any  such  point,  there  being  but  little 
diff'erence  in  this  respect  over  the  whole  of  the  front  surface  of  the 
tumor.  In  such  case  we  may  be  governed  by  the  ordinary  rules  for 
the  place  for  tapping.  The  linea  alba,  between  the  symijhysis  and 
umbilicus,  is  the  most  eligible  in  the  greatest  number  of  cases.  If  any 
objection  to  this  arises,  a  point  midway  between  the  umbilicus  and 
the  anterior  superior  spine  of  the  ilium  is,  as  a  general  thing,  safe 
and  effectual  as  any.  Some  surgeons  recommend  other  places  as  free 
from  the  objections  that  are  sometimes  urged  against  these  points. 
They  say  that  tapping  through  the  vagina  is  quite  safe  from  the 
immediate,  and  not  so  likely  to  be  followed  by  some  of  the  sequential 
disasters.  The  rectum  is  thought  to  be  still  better  by  some.  The 
vagina  is  quite  a  commendable  place,  if  we  are  careful  to  ascertain 


736  OVARIAN   TUMORS. 

well  the  position  of  the  bladder  and  uterus,  and  avoid  them.  Our 
instrument  (the  trocar)  should  be  large,  four  or  five  lines  in  diameter ', 
the  point  should  be  sharp,  and  a  little  longer  tnan  they  are  usually 
made.  The  canula  if  not  large  will  not  freel}'  discharge  the  fibrinous 
concretions  or  thick  treacle-like  fluid,  and  if  the  point  is  not  long  and 
sharp,  we  inflict  considerable  unnecessary  suffering  in  the  introduction 
of  the  instrument.  We  may  plunge  the  instrument  in  towards  the 
central  axis  of  the  tumor,  until  sent  home  to  the  rim  of  the  canula. 
If,  however,  our  instrument  is  not  pretty  sharp,  it  will  be  very  much 
better  to  make  an  opening  through  the  integument  with  a  very  sharp, 
thin  bistoury,  which  will  cause  less  suffering,  and  answer  every  pur- 
pose as  well. 

For  the  purpose  of  avoiding  some  of  the  dangers  connected  with 
tapping,  Mr.  Wells  has  invented  a  trocar  that  prevents  the  ingress 
of  air,  and  attaches  a  rubber  tube  to  the  canula  to  carry  the  fluid 
clear  of  the  patient  and  bed. 

I  have  never  seen  any  serious  effects  follow  tapping  with  these  pre- 
cautions. Notwithstanding  .this  favorable  experience,  I  would  advise 
every  practicable  precaution  recommended  by  these  eminent  observers 
to  avoid  the  disasters  which  have  occasionally  occurred. 

Since  the  general  introduction  of  the  aspirator  many  surgeons 
think  it  better  practice  to  use  that  instrument  in  the  evacuation  of  the 
tumor.  It  has  been  pretty  well  proven,  however,  by  the  late  inves- 
tigation of  Drs.  Lusk  and  Proctor,  that  there  is  not  so  much  diff"er- 
ence  in  dangers  resulting  from  the  use  of  the  aspirator  instead  of  the 
trocar,  as  was  expected  from  the  experience  of  Dieulafoy  and  his  fol- 
lowers. Several  instances  have  been  recorded  in  which  death  oc- 
curred from  the  use  of  the  aspirator. 

The  third  sort  of  cases  to  which  palliative  treatment  is  applicable, 
those  in  which  our  patient  will  not  submit  to  radical  means,  must  be 
managed  in  almost  every  jaarticular  as  I  have  described  the  treatment 
for  the  other  two  kinds.  Remembering  the  rules  and  rationale,  it  will 
not  be  difficult  to  adapt  our  means  to  the  end  in  view. 

Curative  Treatment. 

The  cure  of  ovarian  tumors  is  believed  by  almost  all  authorities  to 
be  practicable  only  by  surgical  means.  There  are  some  very  respect- 
able writers,  however,  who  believe  that  there  are  cases  in  which  we 
may  hope  for  success  from  medicinal  and  mechanical  treatment  with- 
out the  use  of  surgical  instruments,  and  the}^  think  that  there  is  enough 
virtue  in  such  means  to  warrant  a  trial  in  very  many  instances. 

Surgical  Treatment. 

The  resolution  and  absorption  of  ovarian  tumors  is  a  very  doubtful 
fact,  however,  and  notwithstanding  their   unaccountable    disappear- 


SURGICAL    TREATMENT.  737 

ance,  should  not  be  counted  prognostically.  The  second  object  in  our 
treatment,  that  of  obliterating  the  sac  in  situ,  affords  more  reason  for 
hope  in  properly  selected  cases.  The  means  used  consist  of  tapping, 
with  pressure,  with  injections  of  stimulants  to  induce  inflammation 
of  the  sac,  and  with  injections  and  pressure  combined ;  or,  what  is 
sometimes  successful,  the  establishment  of  a  fistulous  opening  in  the 
sac,  that  either  communicates  externally  through  the  abdominal  walls, 
through  the  vagina  or  rectum,  or  simply  with  the  peritoneal  cavity. 
The  above-mentioned  treatment  is  applicable,  properly,  to  the  uniloc- 
ular or  single  cyst  cases  only,  as  it  is  impracticable  to  tap,  inject,  or 
establish  a  fistula,  when  there  are  many  sacs;  and,  what  is  still  more 
discouraging  in  the  multilocular  variety,  the  sacs  are  not  only  filled 
again  after  tapping,  as  is  generally  the  case  with  the  monocyst,  but 
there  is  a  constant  reproduction,  or,  perhaps,  it  would  be  more  cor- 
rect to  say  that  they  are  continuously  developed  from  the  ovisacs  that 
are  matured  every  month.  Tapping,  followed  by  pressure  or  injec- 
tion, is  very  apt  to  change  the  condition  of  the  tumor  in  one  respect, 
at  least,  and  that  is,  to  cause  adhesions  to  the  surrounding  peritoneal 
surface.  In  one  case  of  unilocular  tumor,  in  which  an  external  fistu- 
lous opening  was  made  after  the  patient  had  been  tapped  six  times, 
and  had  iodine  injections  three  times,  the  sac,  so  far  as  we  could  de- 
termine, was  universally  adherent ;  no  portion  of  it  could  be  brought 
out  of  the  wound. 

Very  fortunate  instances  sometimes  occur  in  which  the  evacuation 
'of  the  tumor  by  tapping  is  followed  by  a  speedy  and  permanent 
obliteration  of  the  sac.  It  is  exceedingly  doubtful,  however,  whether 
these  were  not  cysts  developed  from  the  broad  ligament,  and  not 
involving  the  ovarian  tissues  at  all.  Certainly  they  are  exceptional, 
and  cannot  be  expected  in  any  given  case,  so  that  we  ought  never  to 
be  satisfied  with  tapping  when  our  object  is  the  obliteration  of  the 
cyst. 

Pressure,  in  conjunction  with  tapping,  is  applicable,  perhaps,  to  a 
larger  number  of  cases  than  any  of  the  modes  of  treatment  yet  men- 
tioned. It  is  -very  much  more  successful  in  cases  of  the  monocystic 
than  in  any  other  variety.  The  application  of  pressure  to  a  tapped 
sac  has  for  its  object  a  complete  closure  of  the  cavity  of  the  cyst  in 
such  a  manner  as  to  bring  its  walls,  as  nearly  as  practicable,  in  con- 
tact throughout.  This  at  once,  if  thoroughly  effected,  modifies  the 
secerning  capacity  of  its  surface,  and  perhaps,  from  the  time  of  its 
application,  arrests  more  or  less  completely  the  effusion  of  the  fluid. 
Now,  if  this  cannot  be  done  so  as  to  operate  upon  all  the  surface  of 
the  walls,  we  can  almost  always  bring  some  portion  of  the  collapsed 
walls  in  contact.  The  continuous  and  prolonged  contact  of  these  sur- 
faces brings  about  a  low,  and  in  some  cases  a  pretty  high  grade  of 
inflammation,  causing  adhesion  or  a  change  in  their  structure,  so  that 

47 


738  OVARIAN    TUMORS. 

they  are  no  longer  of  the  same  ovisac  nature,  and  hence  they  do  not 
effuse  the  thick  albumen  previously  produced,  and  the  tumor  remains 
inactive  or  shrinks,  and  nearly  or  entirely  disappears  ;  or  suppurative 
inflammation  may  dissolve  down  and  discharge  the  mass  through 
some  adventitious  or  natural  outlet. 

The  manner  of  applying  the  pressure  is  of  the  greatest  importance. 
The  apparatus  should  be  permanent,  and  exert  as  much  force  as  the 
patient  can  bear  without  too  great  pain,  fever,  derangement  of  the 
abdominal  viscera,  or  other  indications  of  too  acute  a  degree  of  in- 
flammation in  the  cyst  or  damage  to  some  organ.  It  should  be  ap- 
plied to  the  tumor  as  nearly  as  possible,  and  the  forcible  pressure 
should  be  exerted  alone  upon  the  collapsed  mass,  so  as  to  crowd  it 
back  against  the  sacrum,  lumbar  muscles,  spine,  and  other  hard  parts 
of  the  posterior  wall  of  the  abdomen.  In  order  to  do  this  properly, 
after  the  fluid  is  evacuated  as  completely  as  possible,  we  should  ex- 
amine the  abdomen  minutely,  so  as  to  ascertain  as  clearly  as  possible 
the  position  of  the  collapsed  cyst.  This  will  usually  be  a  little  more 
to  one  side  than  the  other,  and  we  ma}'  generally  easily  define  its 
shape  and  get  a  good  idea  of  its  size.  We  should  now  construct  a 
compact  compress,  corresponding  in  shape  and  size  with  the  shape 
and  size  of  the  evacuated  sac.  The  compress  should  be  embraced  by 
solid  wood  or  tin  outside.  The  compress  can  be  made  of  hair,  gum- 
elastic  material,  or  napkins.  If  of  the  latter,  they  should  be  well 
stitched  together,  so  that  there  can  be  no  shifting  in  their  position. 
After  firmly  attaching  the  soft  portion  of  the  compress  to  the  hard,  so 
that  any  pressure  upon  the  latter  may  be  exerted  unvaryingly  upon 
the  former,  it  may  be  placed  immediately  over  the  tapped  tumor,  and 
pressure  applied  from  a  direction  to  press  it  against  the  hardest  part, 
bearing  on  the  posterior  walls  of  the  abdomen  or  pelvis.  An  atten- 
tive examination  of  the  tumor  under  the  pressure  of  the  instrument 
will  inform  us  pretty  accurately  as  to  the  efl&ciency,  completeness, 
and  direction  of  the  pressure  of  the  compress.  The  compress  may 
be  managed  better  by  a  belt  of  soft  but  firm  leather,  to  surround  the 
body  in  such  a  place  as  to  press  over  the  centre  of  the  compress. 
The  power  and  direction  of  the  pressure  may  be  regulated  thoroughly 
and  at  will  by  subjecting  it  to  a  tourniquet  screw  pressure  from  the 
belt.  Of  course  there  must  be  thigh  and  shoulder-straps  to  the  belt, 
in  order  to  keep  it  from  slipping  up  or  down.  When  we  have  adapted 
these  simple  contrivances,  we  should  turn  the  screw  to  such  a  degree 
as  to  press  strongly  as  the  patient  can  bear,  and  with  it  thereafter 
regulate  the  pressure  as  we  may  judge  best.  Having  thoroughly 
satisfied  ourselves  of  the  appropriate  adaptation  of  the  apj^aratus,  we 
should  wrap  the  whole  abdomen  agreeably  tight,  from  pubis  to  sternum, 
with  a  flannel  roller.  We  should  every  day  remove  the  flannel  roller, 
and  examine  the  compress  and  belt  to  be  sure  that  they  are  not  dis- 


SURGICAL   TREATMENT.  739 

arranged,  and  if  in  the  least  so,  we  should  readapt  them.  We  may- 
tighten  the  screw  or  loosen  it  each  time,  or  allow  it  to  remain  untouched, 
as  the  case  may  he.  The  greatest  care  should  he  taken  not  to  produce 
too  great  pressure  with  this  compress.  It  should  be  loosened  when 
chilliness,  febrile  excitement,  or  other  general  signs  of  distress  are 
added  to  local  pain  ;  it  may  be  tightened  as  soon  as  the  symptoms 
decline. 

This  mode  of  applying  pressure,  I  think,  is  much  more  efficient  and 
manageable  than  the  plan  recommended  by  the  late  Mr.  I.  B.  Brown, 
of  London,  the  accomplished  surgeon  of  female  diseases  and  injuries. 
His  plan  is  to  make  a  graduated  compress  of  napkins  so  as  to  fit  the 
top  of  the  pelvis,  and  after  applying  it  over  the  tumor,  so  as  to  press 
it  down  into  the  pelvic  cavity  and  against  its  back  part,  place  over 
the  whole  a  broad  bandage  tightly  fastened  from  pubes  to  sternum. 
This  kind  of  compress  cannot  always  be  accurate  in  the  extent,  posi- 
tion, and  rate  of  its  pressure,  and,  consequently,  much  more  skill 
and  experience  are  necessary  in  its  application.  Its  success,  hence, 
was  much  more  frequent  in  Mr.  Brown's  hands  than  it  has  been  with 
the  profession  generally.  I  am  not  aware  that  Mr.  Brown  teaches 
the  necessity  of  pressure  to  all  the  collapsed  tumor,  but  understand 
him  to  make  most  of  his  pressure  at  the  origin  of  the  tumor, — the 
ovarian  region.  The  tumor,  Avhen  collapsed  by  tapping  after  great 
distension,  seldom  sinks  anything  more  than  partially  into  the  pelvis ; 
the  long-exercised  traction  upwards  generally  lifts  the  ovary  of  that 
'side  above  the  pelvis,  and  thus  we  may  generally  somewhat  accurately 
fit  our  means  to  its  slope  and  position.  An  objection,  Mr.  Brown 
thinks,  sometimes  apj^lied  to  pressure,  is  the  presence  and  great  aggra- 
vation of  prolapsus  uteri.  This  objection,  it  will  be  apparent,  is  very- 
much  more  applicable  to  his  mode  of  causing  it  than  the  one  I  recom- 
mend. Multilocular  tumors  may  be  cured  in  this  way  perhaps  more 
frequently  than  any  other  except  extirpation,  for  the  pressure  may- 
be made  to  bear  upon  and  greatly  influence  the  development  of  the 
small  cysts  that  are  not  evacuated  by  pressure.  I  have  more  than 
once  evacuated  several  sacs  through  one  opening  in  the  abdominal 
walls  by  partially  withdrawing  the  trocar,  and  directing  the  point 
toward  a  full  sac  after  the  one  first  pierced  had  been  evacuated.  This 
should  be  attempted  in  a  multilocular  tumor  before  we  use  pressure, 
and  it  is  allowable,  I  think,  to  introduce  the  trocar  in  several  places 
where  there  are  a  number  of  cysts  that  cannot  be  reached  by  the  in- 
strument from  one  point.  I  would  not  be  understood  as  advising  a 
reckless  use  of  the  trocar  in  these  many-cysted  ovarian  tumors,  but 
after  we  have  decided  from  the  circumstances  of  a  careful  examination 
of  a  given  case  that  tapping  and  pressure  is  the  treatment,  we  risk 
nothing,  I  think,  in  being  thorough  in  our  efforts  to  evacuate  as  nearly 
as  possible  all  the  sacs.     The  bad  effects  arising  from  tapping  and 


740  OVARIAN   TUMOES. 

pressure  are  inflammation  and  its  consequences.  When  there  are 
symptoms  of  severe  acute  inflammation,  the  pressure  should  be  re- 
moved, and  leeches,  cathartics,  etc.,  should  be  employed  to  moderate 
or  remove  it.  If  the  inflammation  is  in  the  sac,  we  should  wait  until 
all  the  acute  symptoms  subside  before  the  pad  or  compress  is  placed 
again.  If,  however,  we  can  satisfy  ourselves  that  the  inflammation  is 
in  some  other  part  distressed  by  the  pressure,  by  varying  the  direction 
of  the  pressure,  provided  we  can  include  the  tumor  under  it,  we  need 
not  wait  until  all  the  acute  symptoms  have  vanished.  I  have  a  better 
opinion  of  this  kind  of  treatment,  when  carefully  managed  and  watched, 
than  any  other,  excej^t  the  complete  extirpation  of  the  ovary. 

Injection  of  the  Sac. 

Another  plan  of  obliterating  the  sac  of  ovarian  tumors  is  to  first 
evacuate,  and  then  inject  it  with  some  substance  calculated  to  induce 
inflammation  in  it,  which,  by  its  adhesive  or  destructive  processes, 
may  completely  effect  this  object.  A  large  number  of  cases  are  re- 
ported cured  by  this  plan  of  treatment.  For  obvious  reasons  it  is 
almost  exclusively  confined  in  its  usefulness  to  the  unilocular  variety. 
Under  certain  circumstances  only  can  we  expect  to  reach  more  than 
one  cyst  at  a  time  with  the  trocar  and  injections.  When  a  cyst  is 
simple,  the  patient  in  good  health,  and  we  succeed  in  properly  man- 
aging the  operation,  there  is  not  a  great  deal  of  danger,  and  we  may 
reasonably  hope  for  benefit  from  it.  The  most  simple,  and  I  think 
effective  mode  of  operating,  is  to  first  draw  off  nearly  all  the  fluid, 
except,  say,  one  or  two  pounds,  as  well  as  we  can  judge  of  it,  with 
a  lai'ge  trocar.  After  this  is  accomplished,  we  should  j^ass  an  elastic 
catheter  or  other  flexible  tube  through  the  canula  of  the  trocar  to 
the  bottom  of  the  cavity.  With  a  hard  rubber  syringe  we  may  in- 
ject the  medicine,  whatever  that  may  be,  through  the  catheter  into 
the  interior  of  the  cyst.  By  using  this  elastic  tube  there  is  no  danger 
of  failing  to  carry  the  material  to  the  part  we  'desire  to  reach  without 
its  coming  in  contact  with  anything  else,  or  being  decomposed  before 
it  arrives  at  its  destination.  The  formula  for  this  kind  of  injections 
are  numerous,  and  several  different  substances  used.  Iodine  seems 
now  to  be  the  substance  generally  employed.  Dr.  Simpson  recom- 
mends several  ounces  of  the  tincture.  Six  ounces  is  probably  enough 
to  use  at  one  time.  I  have  used  on  several  occasions  six  ounces  of  a 
mixture  containing  one  scruple  of  iodine,  two  scruples  of  iod.  potass, 
to  the  ounce  of  water.  This  is  certainly  iodine  enough,  if  specific  in 
its  influence,  to  cure  any  tumor.  My  plan  is  to  allow  it  to  remain  in 
tiie  sac  instead  of  removing  any  of  it. 

lodism  is  likely  to  occur  to  a  slight  extent,  but  is  the  source  of 
no  considerable  inconvenience.     If  it  should  be  thought  best  to  re- 


INJECTION    OF    THE    SAC.  741 

move  a  part,  or  the  whole  of  the  iodine,  the  better  way  to  do  it  is  to 
pump  it  out  through  the  tube  by  which  it  was  introduced,  instead 
of  squeezing  it  back  through  the  canula  of  the  trocar.  This  plan  of 
extracting  it,  precludes  the  possibility  of  allowing  any  contact  with 
the  peritoneum;  which  in  the  event  of  disarrangement  of  the  canula 
might  otherwise  take  place.  Although,  ordinarily,  no  great  amount 
of  acute  inflammation  takes  place  as  the  effect  of  this  injection,  yet 
we  should  remember  that  it  sometimes  does  proceed  to  a  danger- 
ous extent,  and  be  upon  our  guard  with  the  means  necessary  to 
prevent  a  fatal  degree.  In  fact,  it  would  be  negligence  on  our 
part  not  to  watch  with  solicitude  all  the  most  trifling  operations 
upon  an  ovarian  cyst.  It  may  be  asked  whether  iodine  is  the  best 
substance  to  use  as  an  injection  in  such  cases?  Although  I  have  to 
some  extent  fallen  in  with  the  fashion  of  using  iodine,  I  cannot  resist 
the  conviction  that  there  are  substances  that  would  do  as  well,  against 
which  some  objections  that  apply  to  iodine  could  not  be  urged. 
Iodine  operates  promptly  upon  the  organism  when  introduced  in  this 
way,  by  being  absorbed  and  taken  into  the  circulation ;  yet,  I  think 
there  can  be  but  few  who  desire  anything  more  than  its  local  eflect 
upon  the  inner  surface  of  the  sac.  Alcohol,  wine,  brandy,  in  fact  any 
local  stimulant  whose  general  effect  after  absorption  is  more  transient, 
as  well  as  less  powerful,  would  perhaps  answer  just  as  well.  It  can- 
not be  that  the  internal  effects  of  iodine  upon  the  kidneys  and  other 
.  organs  of  excretion  can  enter  largely  into  its  good  effects,  for  if  such 
were  the  case  it  would  be  better  given  by  the  stomach.  Injection  of 
iodine  was  regarded  several  years  ago  as  the  most  eligible  mode  of 
treating  this  affection,  because  of  its  comparative  safety  and  frequent 
success ;  but  there  can  be  no  doubt  that  it  was  overrated,  and  now 
the  profession  is  less  ready  to  trust  it.  I  believe  it  to  be  both  more 
dangerous  and  less  efficient  than  pressure  after  tapping.  This  is  not 
in  accordance  with  the  opinion  of  Dr.  Simpson,  I  believe.  I  have 
lately  known  of  a  case  in  which  death  occurred  after  having  been 
treated  with  iodine  injections  combined  with  pressure.  I  speak  of 
this  case  to  warn  against  a  similar  procedure,  for  it  is  plain,  upon  a 
little  reflection,  that  if  the  pressure  is  properly  applied,  it  will  so  lessen 
the  cavity  of  the  cyst  as  to  endanger  the  effusion  of  the  iodine,  through 
the  puncture  in  the  sac,  into  the  peritoneal  cavity,  and  thus  induce  a 
fatal  peritonitis.  And  if  pressure  is  to  be  used,  we  should  wait  for 
two  or  three  days  after  the  injection. 

The  last,  and  doubtless  most  effectual  plan,  for  obliterating  the 
sac,  is  the  establishment  of  a  fistulous  opening,  communicating  with 
the  peritoneal  cavity,  or  the  external  surface,  directly  or  indirectly, 
through  the  vagina  or  rectum.  This  is  also  the  most  dangerous  plan, 
resulting  fatally  in  a  large  number  of  cases.  Quite  a  difference  in  the 
effects,  both  remedial  and  morbid,  may  be  remarked  in  the  different 


742  OVAEIAX    TUMOES. 

places  for  the  fistulous  opening.  When  properly  and  carefully  man- 
aged, the  opening  in  the  peritoneal  cavity  is  productive  of  least 
harm,  and  less  likely  to  be  followed  by  a  cure.  The  opening  in  the 
vagina  is  more  effective,  and  the  direct  opening  through  the  abdomi- 
nal walls  both  more  efficacious  and  more  hazardous  than  any  of  the 
others.  When  a  communication  is  perfected  and  perpetuated  between 
the  cavities  of  the  tumor  and  the  peritoneum,  the  surface  of  the  latter 
being  a  better  absorbing  surface,  the  contents  are  absorbed,  thrown 
into  the  circulation,  and  eliminated  by  excretion  through  the  kidneys 
and  alimentary  canal.  This  process  being  carried  on  more  rapidly 
than  the  secretion  by  the  tumor,  the  latter  is  allowed  to  contract  more 
and  more,  until  its  secreting  surface  is  wholly  lost,  and  indurated  tis- 
sue is  all  that  is  left  behind  to  mark  its  former  existence.  Some  very 
important  precautions  are  necessary  for  such  happy  results,  as  will 
appear  by  an  attentive  consideration  of  the  subject.  It  is  found,  for 
instance,  that  sometimes  the  contents  of  the  tumor  are  septic  to  the 
peritoneal  lining  of  the  abdomen,  and  may  therefore  cause  fatal  in- 
flammation upon  its  effusion  into  the  cavity.  We  cannot  say,  without 
an  inspection  of  the  fluid,  whether  this  is  likely  to  occur  upon  per- 
formance of  an  operation  or  not,  and  I  fear  that  we  can  by  that  means 
arrive  at  only  a  presumption  upon  the  subject.  In  evacuating  these 
growths  for  the  first  time  we  find,  occasionally,  clear,  transparent,  good, 
innocent-looking  fluid  begin  to  flow,  when,  as  the  flow  continues,  the 
latter  part  looks  darker,  grumous,  and  ill-conditioned.  Now,  it  is 
a  question  whether  we  might  not  be  deceived  upon  inspection,  and 
really  furnish  a  virus  to  the  surface  of  the  peritoneum,  instead  of  the 
bland  albumen  of  the  healthy  ovarian  tumors.  However  this  may 
be,  we  do  know,  from  cases  placed  on  record  by  Dr.  Simpson  particu- 
larly, and  observed  not  unfrequently,  that  these  tumors  do  some- 
times burst  into  the  abdominal  cavity,  and  disappear,  ^dthout  any 
bad  symptoms,  so  that  we  are  justifiable  in  hoping  the  artificial  open- 
ing may  result  well.  Dr.  Simpson  recommends  (and  it  is  certainly 
the  most  sure  way,  although,  as  I  have  remarked,  we  must,  under  all 
circumstances,  be  in  doubt),  prior  to  opening  communication  with  the 
peritoneal  cavity,  that  we  tap  the  tumor,  and  remove  some  of  the  fluid 
for  examination,  and  if  it  is  the  ordinary  bland,  mucilaginous,  trans- 
parent substance  found  generally  after  first  tapping,  he  assures  us  we 
may  proceed  to  the  operation  unhesitatingly  ;  or,  rather,  may  keep 
the  puncture  in  the  sac  open  afterwards,  instead  of  allowing  it  to  close 
up,  as  it  usually  does.  This  is  done  by,  in  the  first  place,  not  re- 
moving nearly  all  the  fluid  from  the  sac  by  tapping,  but  allowing 
enough  to  remain  to  keep  it  partially  distended ;  and,  in  the  second 
place,  every  twenty-four  hours  so  to  press  upon  the  tumor  as  to  well 
up  the  fluid  through  the  opening  in  the  sac,  and  thus  break  the  slight 
adhesions  which  may  have  formed  between  the  edges  of  the  wound, 


injectio:n-  of  the  sac.  743 

and  allow  it  to  escape  into  the  peritoneani.  Dr.  Simpson  thinks  this 
is  the  safer  way,  so  far  as  the  danger  from  the  operation  is  concerned, 
but,  as  will  be  seen,  not  so  certain  of  accomplishing  the  object.  He 
has  cured  cases  in  this  way.  The  most  etfectual  and  the  most  danger- 
ous way  is  to  cut  down  upon  the  tumor,  and  remove  a  piece  from  its 
wall  large  enough  to  insure  patency,  withdraw  a  part  of  the  fluid, 
and  then  close  the  wound  in  the  abdomen,  and  allow  the  rest  of  the 
fluid  to  flow  into  the  peritoneal  cavity  thence  to  be  absorbed.  The 
immediate  danger  in  this  operation  is  that  of  dividing  some  of  the 
bloodvessels  which  ramify  through  the  walls  of  the  tumor,  and  thus 
allow  internal  hemorrhage  to  take  place.  To  avoid  this  it  is  recom- 
mended by  Mr.  Brown  to  draw  out,  examine,  and  divide  only  that 
portion  which  is  clear  of  vascular  ramifications.  Others  have  recom- 
mended to  tie  an}^  branch  large  enough  to  bleed.  There  is  but  little 
doubt  that  the  2:)recaution  recommended  by  Mr.  Brown  would  be  suf- 
ficient to  avoid  that  difiiculty.  The  large  wound  through  the  peri- 
toneum makes  the  chance  of  inflammation  in  that  membrane  greater 
than  the  mere  puncture  of  the  trocar.  Upon  the  whole,  I  think  I 
should  prefer  Dr.  Simpson's  plan  of  keeping  the  opening  made  by  the 
trocar  in  the  tumor  patent,  by  frequent  well-directed  manipulation. 
It  ought  to  be  practiced,  I  think,  oftener  than  every  twenty-four 
hours  ;  as  often  as  every  twelve,  for  the  first  two  days.  It  will,  prob- 
ably, be  found,  upon  extensive  trial,  that  it  may  not  always  be  prac- 
ticable. Should  there  be  adhesion  at  the  point  where  the  trocar 
passes,  it  would  necessarily  fail. 

The  plan  for  making  a  fistulous  opening  externally  is  more  prac- 
ticable, perhaps,  than  the  one  just  detailed,  from  the  consideration 
that  it  is  more  manageable. 

The  operation  is  simple,  and  not  attended  with  much  immediate 
danger,  the  danger  coming  in  the  shape  of  acute  inflammation  soon 
after  the  operation,  or  exhausting  suppurative  inflammation  and  its 
attendants.  Mr.  Brown,  who  has  given  it  a  more  extensive  trial  than 
anybody  else,  selects  a  point  midway  between  the  umbilicus  and  the 
anterior  superior  spines  of  the  ilium  of  the  side  in  which  the  tumor 
originated.  His  plan  is  to  make  an  angular  incision  at  this  point 
down  to  the  peritoneum,  dissect  up  the  angle  from  that  membrane  so 
as  to  completely  expose  it,  evacuate  the  tumor  through  this  exposed 
part  with  a  trocar,  stitch  the  sac  to  the  sides  of  the  opening,  enlarge 
the  puncture  in  the  cyst,  and  keep  it  open  by  a  pledget  of  lint  or 
other  substance,  as  he  finds  most  convenient.  Others  cut  down  to  the 
peritoneum,  at  a  point  midway  between  the  umbilicus  and  symphysis 
pubis,  stitch  the  sac  to  the  sides  of  the  wound,  and  keep  open  by  lint 
or  the  stomach-tube.  Care  should  be  taken,  especially  if  the  contents 
of  the  sac  should  have  a  suspicious  appearance,  to  prevent  it  escaping 
into  the  jjeritoneal  cavity.     Often  there  is  adhesion  at  this  part,  when 


744  OVARIAN    TUMORS. 

the  stitches  will  not  be  necessary.  This  opening  should  be  kept 
patent  until  the  cavity  of  the  cyst  is  lost  by  contraction,  inflammatory 
adhesion,  or  granulation,  or  all  these  combined,  which  is  probably 
the  common  mode  of  their  disappearance.  Some  difhculty  will  be 
found  in  doing  this,  there  is  such  a  strong  tendency  in  the  wound  to 
contract  and  heal  up  by  granulation.  If  necessary,  we  may  from 
time  to  time  somewhat  enlarge  it  with  the  knife,  and  we  should  not 
allow  it  to  close  until  the  discharge  has  entirely  ceased.  From  what 
I  can  see  of  the  dangers  of  this  operation,  they  are  very  little,  if  any, 
less  than  those  of  ovariotomy,  and  I  should  not  feel  induced  to  resort 
to  it  unless  it  were  in  a  simple  cyst,  where  tapping,  injection  of  iodine, 
or  the  use  of  pressure  had  entirely  failed,  or  where,  after  exposing 
the  cyst,  ovariotom}'-  was  found  impracticable  from  extensive  adhe- 
sions. This  I  have  done  in  one  instance.  The  adhesions  were  so 
extensive  that  the  cyst  could  not  be  removed ;  in  fact,  they  seemed  to 
be  about  universal ;  the  incision  was  small,  only  admitting  two  fingers ; 
the  sac  had  adhered  at  the  point  where  the  opening  was  made,  so  the 
incision  was  all  that  was  necessary  in  the  way  of  an  operation.  The 
patient  died  of  acute  peritoneal  inflammation  in  three  days  afterwards. 
A  post-mortem  examination  revealed  extensive  inflammation  of  the 
sac  and  peritoneum. 

Professors  Kiwisch  and  Scanzoni,  of  Wurtzburg,  were  warm  advo- 
cates of  a  fistulous  opening  through  the  vagina  into  the  tumor,  to  be 
kept  open  until  the  same  obliteration  takes  place  that  was  spoken  of 
as  occurring  in  the  case  of  opening  through  the  front  walls  of  the 
abdomen.  Scanzoni  operated  on  fourteen  cases:  eight  resulted  in  a 
perfect  cure ;  in  two,  the  fluid  collected  again  in  a  few  weeks ;  one 
died  of  typhus  fever  two  months  after ;  and  three  were  lost  sight  of. 
In  none  of  the  fourteen  did  death  occur  as  a  consequence  of  the  pro- 
ceeding. He  mentions  one  case  only,  in  his  whole  experience,  in 
which  death  occurred  from  peritonitis,  and  that  was  Professor  Ki- 
wisch's  case.  Scanzoni  admits  its  danger,  but  shows  quite  a  favor- 
able opinion  of  it.  Dr.  West  gives  three  cases  of  his  own,  two  of 
which  were  cured,  but  had  formidable  inflammation  ;  the  third  died, 
not  as  an  effect  of  the  operation,  but  from  something  else,  which  he 
does  not  state.  Scanzoni  taps  with  a  trocar  through  the  vagina,  and 
allows  the  canula  to  remain  until  the  cure  is  effected.*  This,  of 
course,  occupies  a  variable  time.  The  tube  is  withdrawn  by  Scanzoni 
by  the  eight  or  tenth  day  in  some  cases.  He  says  that  some  of  his 
cases  recovered  without  any  sign  of  inflammation  or  other  inconveni- 
ence.    Dr.  West  operates  by  introducing  the  trocar  and  withdrawing 


*  The  only  case  I  have  operated  on  in  this  way  died  of  pyemia  from  suppuration 
of  the  cyst.     Tlie  caniila  remained  for  fifteen  days. 


ELECTEOLYSIS.  745 

the  fluid,  passing  a  number  twelve  catheter  through,  and  removing 
the  canula  over  the  catheter.  The  catheter  is  allowed  to  remain  until 
the  cure  is  complete.  The  cyst  cannot  always  be  reached  from  the 
vagina,  and  only  in  cases  where  it  is  crowded  down  into  the  pelvis, 
so  as  to  give  obvious  fluctuation  in  that  canal,  should  we  think  of  this 
operation. 

When  the  cyst  is  discovered  while  yet  small  and  occupying  the 
posterior  cul-de-sac,  tapping  and  drainage  will  often  result  in  a  cure. 
I  have  once  succeeded  in  obliterating  a  tumor  as  large  as  an  orange 
by  this  method.  Dr.  Emil  Noeggerath,  of  New  York,  thinks  their 
growth  may  be  arrested  with  much  certainty  by  puncturing  them 
with  a  very  fine  trocar  or  hypodermic  syringe.  He  says  he  has 
treated  about  ten  cases  by  this  method,  and  is  so  well  satisfied  with 
the  results  as  always  to  attempt  the  cure  of  small  cysts  in  this  way. 
He  has  also  improved  upon  the  operation  of  Kiwisch  and  Scanzoni 
by  making  a  free  incision  into  them  through  the  vagina,  and  stitching 
the  sac  to  the  incision.  He  has  thus  succeeded  in  draining  quite  a 
number  of  large  ovarian  cj^sts.  Another  method  of  treating  these 
small  cysts,  original  with  Dr.  Noeggerath,  consists  in  rupturing  them 
by  pressure  between  the  fingers  of  one  hand  in  the  vagina  and  those 
of  the  other  above  the  symph^^sis  pubis.* 

Electrolysis. 

Among  the  expedients  for  the  treatment  of  ovarian  tumors  must  be 
enumerated  electrolysis,  for  although  it  has  not  been  subjected  to  the 
test  of  experience,  yet  there  have  been  a  number  of  undoubted  cases 
of  cure  by  this  process. 

Dr.  Paul  F.  Munde,  in  an  exhaustive  paper,  published  in  the  second 
volume  of  American  Gynecological  Transactions^  sums  up  the  result  of 
his  research  thus :  "  Out  of  fifty-one  cases  twenty-eight  were  either 
completely  cured  or  permanently  relieved.  This  makes  about  fifty- 
five  per  cent.  Thirteen,  or  25.4  per  cent.,  were  followed  by  dangerous 
and  even  fatal  results,  nine  of  which,  or  17.6  per  cent.,  proved  fatal. 
Six  cases  were  not  affected  by  the  treatment,  and  four  were  tempo- 
rarily improved.  Thus  in  twenty-three  cases,  or  45  per  cent.,  the 
objects  of  treatment  were  not  attained." 

It  is  not  fair,  however,  to  compare  the  results  of  oophoro-electro- 
lysis  with  ovariotomy  as  practiced  by  expert  ovariotomists,  because 
electrolysis  is  in  its  infancy,  while  ovariotomy  has  undergone  vast  im- 
provements since  it  was  first  introduced.  If  we  recall  the  time  when 
ovariotomy  was  regarded  as  an  unjustifiable  operation  on  account  of 
its  want  of  success,  and  remember  that  the  fatality  of  that  operation 

*  Second  volume  Transactions  of  the  American  Gynecological  Society. 


746  OVA  EI  AX    TUMORS. 

depended  greatly  upon  the  imperfection  of  its  execution,  and  greater 
lack  of  skill  in  the  after-treatment,  we  are  warranted  in  indulging  the 
hope  that  electrolysis  may  some  day  emerge  from  its  present  uncer- 
tainty and  claim  success  to  a  degree  sufficient  to  be  applicable  to  cer- 
tain conditions  of  ovarian  cases. 

There  are  two  methods  of  applying  electrolysis  to  ovarian  tumors ; 
one  is  the  external  or  percutaneous,  in  which  the  electrodes  are  ap- 
plied over  the  skin  in  such  a  manner  as  to  allow  the  current  to  pass 
through  the  tumor.  This  method  is  less  prompt  and  also  less  dan- 
gerous in  its  effects. 

Chiari  reports  a  case  in  which  there  was  great  constitutional  debility 
caused  by  some  three  hundred  sittings.     (Dr.  Munde's  paper.) 

The  other  plan  of  electrolyzing  the  tumor  consists  in  inserting  one 
or  more  needles  into  the  tumor  and  connecting  it  or  them  with  one 
electrode,  while  the  other  electrode  is  applied  over  the  surface  of  the 
tumor  or  in  the  vagina,  or  by  applying  both  electrodes  to  needles  in- 
troduced into  different  parts  of  the  tumor. 

Experimenters  in  this  practice  are  not  sufficiently  definite  as  to  the 
kind  of  battery,  the  strength  of  current,  the  frequency  or  length  of 
time  of  each  sitting.  These  conditions,  as  well  as  the  character  of 
tumors  likely  to  yield  to  the  treatment,  are  points  to  be  ascertained 
by  further  experiment.  Neither  is  it  yet  determined  whether  the 
constant  current  or  the  induced  is  the  better  to  use. 

Dr.  Trommhold,  of  Buda  Pesth,  is  reported  by  Semeleder  to  have 
cured  an  ovarian  cyst  by  the  external  application  of  the  Faradian 
current. 

For  further  information  on  this  interesting  subject,  I  would  refer 
the  reader  to  Dr.  Munde's  paper,  and  to  one  in  the  New  York  Medical 
Journal,  of  June,  1876,  by  Dr.  Frederic  Semeleder. 

The  third  object  in  the  treatment,  partial  or  complete  removal  of 
the  growth,  remains  to  be  considered. 

Vaginal  Ovariotomy. 

Several  cases  of  vaginal  ovariotomy  are  now  on  record,  by  Drs. 
Thomas,  J.  F.  Gilmore,  of  Mobile,  C.  E.  Wing,  of  Boston,  W.  Goodell, 
R.  Davis,  of  Wilkesbarre,  Pa.,  Robert  Battey,^  Henry  T.  Byford,  and 
W.  L.  Atlee,  all  of  which  were  successful. 

The  practice  originated  with  Dr.  Thomas.  The  operation  consists 
in  making  a  median  line  incision  through  the  posterior  wall  of  the 
vagina  behind  the  cervix,  puncturing  the  cyst,  withdrawing  it,  and 
tying  the  pedicle. 

Dr.  Thomas  ligated  and  returned  the  pedicle,  and  closed  up  the 
wound.     The  most  disagreeable  circumstance  following  his  operation 

*  Emmet's  Principles  and  Practice  of  Gynecology. 


TAGIXAL   OVARIOTOMY.  747 

was  a  smart  attack  of  pelvic  cellulitis.  In  Dr.  Goodell's  case  the  cyst 
was  in  a  state  of  suppurative  inflammation,  and  had  contracted  many 
adhesions,  which  he  overcame  by  introducing  the  fingers  through  the 
incision  and  traction  with  the  vulsellum  forceps.  One  of  Henry  T. 
Byford's  cases  was  a  small  dermoid  tumor  firmly  attached  over  the 
sacro-uterine  ligament,  accompanied  by  an  obliteration  (or  absence) 
of  the  vaginal  portion  of  the  sacro-uterine  pouch.  The  difiQculties, 
chiefly  on  account  of  the  fact  that  the  patient  was  a  virgin,  were  great, 
but  not  insurmountable.  His  other  case,  a  monocyst,  was  removed 
with  great  ease.  Both  recovered  with  scarcely  any  reaction.  Dr. 
Atlee's  case,  the  first  on  record  (1857),  consisted  of  a  tumor  dragged 
down  between  a  prolapsed  bladder  and  rectum,  the  ovarian  origin  of 
which  had  not,  however,  been  previously  discovered. 

The  expediency  of  this  operation  is  unquestionable  where  the  diag- 
nosis is  complete,  because  the  favorable  termination  of  the  cases  indi- 
cates a  greater  degree  of  safety  than  abdominal  ovariotomy. 

I  decidedly  favor  the  idea  of  leaving  a  drainage  tube  in  the  vaginal 
incision  for  twenty-four  or  forty-eight  hours,  in  conjunction  with  a 
tampon  of  loose  iodoform  ga'uze.  The  entire  operation  should  be  done 
in  the  dorsal  position. 


CHAPTER    XLiy. 

ABDOMI^'AL  OVARIOTOMY. 

General  Observations. 

During  the  time  that  surgeons  were  experimenting  with  different 
methods  of  performing  ovariotomy,  the  incision  was  made  in  different 
localities,  but  now  all  oj^erators  make  it  in  the  linea  alba,  and  between 
the  umbilicus  and  the  pubis. 

As  to  the  length  of  the  incision,  the  exigencies  of  the  case  must 
govern  us.  Three  inches  will  often  be  suflSciently  long  to  permit  the 
removal  of  an  oligocystic  tumor  with  slight  or  no  adhesions ;  much  more 
frequently,  however,  it  will  be  necessary  to  make  the  incision  five 
inches  long ;  very  seldom  will  it  be  necessary  to  make  it  longer  than 
this. 

Mr.  Wells  thinks  that  incisions  which  do  not  extend  above  the  um- 
bilicus are  safer  than  those  which  do.  Dr.  Peaslee  believes  that  the 
incision  may  be  too  short;  less  than  three  inches  he  thinks  more 
dangerous  than  a  greater  length.  The  practical  rule,  according  to 
Peaslee*  (and  I  fully  concur  with  it),  is  to  make  the  opening  into  the 
peritoneal  cavity  for  the  removal  of  the  tumor  at  least  three  inches 
long  at  first,  then  to  prolong  it  if  necessar}^  and  only  so  far  as  is 
actually  required. 

If  the  incision  is  to  be  carried  above  the  umbilicus,  it  should  be 
carried  around  to  the  left  and  then  back  to  the  linea  alba. 

Treatment  of  the  Pedicle. 

Mr.  I.  Baker  Brown,  according  to  Peaslee,  first  used  the  actual 
cautery  to  divide  the  pedicle.  A  clamp  is  first  applied  so  as  to  secure 
and  fix  the  pedicle,  and  then  the  cautery  at  a  red  heat  is  applied  in 
such  a  manner  as  to  cook  the  parts  between  the  tumor  and  the  clamp, 
and  in  the  jaws  of  the  clamp,  and  afterward  to  burn  through  the 
pedicle  and  thus  separate  it. 

If  we  have  the  iron  at  so  low  a  temperature  that  we  can  make  a 
prolonged  contact  and  pass  it  over  a  larger  space,  the  coagulation  of 
the  albumen  in  the  tissue  is  so  comiDlete  that  there  is  no  danger  of 
hemorrhage. 

If,  however,  the  cautery  is  very  hot,  it  will  sever  the  arteries  with- 

*  Ovarian  Tumors,  p.  417. 


THE   LIGATURE.  749 

out  consolidating  the  parts,  and  thus  permit  as  free  bleeding  as  if  the 
division  was  made  by  the  knife  or  scissors. 

The  therm o-cautery  of  Paquelin,  or  the  galvano-cautery,  are  the 
handiest  instruments  with  which  to  cauterize  the  pedicle,  but  iron 
cauteries  heated  by  properly  constructed  blowpipes,  or  a  small  porta- 
ble furnace,  such  as  is  used  by  tinners  for  soldering  purposes,  will 
answer  better. 

Dr.  G.  H.  B.  McLeod,  of  Glasgow,  first  conceived  and  executed  the 
idea  of  securing  the  vessels  by  torsion  of  the  whole  pedicle.  He 
twisted  it  wuth  two  stout  forceps.  Torsion  of  the  vessels  separately 
has  also  been  practiced  successfully. 

The  ecraseur  has  been  used  for  dividing  the  pedicle.  In  my  first 
case  of  ovariotomy  I  divided  the  pedicle  with  that  instrument,  and 
secured  it  in  the  wound  with  its  edge  upon  a  level  with  the  skin  by 
passing  the  pins  through  it  with  which  I  closed  the  wounds. 

Many  other  methods  of  securing  the  vessels  in  the  pedicle  have 
been  devised,  a  thorough  summary  of  which  may  be  found  in  the 
admirable  work  of  Dr.  Peaslee,  above  mentioned,  to  which  I  would 
refer  all  who  wish  to  study  the  subject  in  an  extensive  manner. 

The  Ligature. 

The  kind  of  material  used  for  ligating  the  pedicle  has  engaged  the 

attention  of  the  profession  for  a  long  time.     Silk,  hemp,  catgut,  horse- 

-hair,  fibres  from   tendons   of  animals, — notably  the   deer, — metallic 

wire,  etc.,  have  all  been  used  successfully,  and  most  of  them  earnestly 

recommended  by  those  who  have  tried  them. 

Four  qualities  seem  to  be  of  material  importance,  if  not  essential  to 
uniform  success,  viz. :  1st.  Sufficient  pliability  to  secure  perfect  adap- 
tation to  the  inequalities  of  the  structure  and  density  of  the  pedicle. 
2d.  Strength  to  bear  the  force  necessary  to  complete  the  constriction 
of  the  vessels.  3d.  Solidity  enough  to  resist  the  effects  of  moisture  for 
a  sufficient  time.  4th.  Absorbability.  Of  all  the  articles,  mentioned 
in  the  list  I  think  silk  is  the  only  one  that  presents  all  these  qualities 
to  any  desirable  extent,  and  I  think  it  is  now  generally  regarded  as 
the  best  material  for  ligation  of  the  j)edicle. 

The  ligature  should  be  long  enough  to  enable  the  surgeon  to  manip- 
ulate it  easily  and  handle  it  securely.  If  the  pedicle  is  of  sufficient 
length  to  permit  of  it,  we  should  not  apply  it  nearer  than  an  inch  to 
the  tumor,  and  then  separation  should  be  made  close  to  the  tumor, 
thus  giving  almost  an  inch  of  tissue  beyond  the  ligature.  If  the 
pedicle  is  too  short  for  this  we  ought  to  cut  into  the  tumor  to  lengthen 
out  the  substance  beyond  the  ligature.  This  will  do  away  with  the 
danger  of  retraction  and  consequent  loosening  of  the  ligature.  In  a 
fleshy  pedicle  it  is  better  also  to  ligate  the  arteries  separately.     I  have 


750  ABDOMINAL   OVARIOTOMY. 

known  of  one  fatal  case  of  hemorrhage  resulting  from  retraction  of 
the  tissue  of  the  pedicle  through  the  ligature  that  I  have  no  doubt 
might  have  terminated  otherwise  if  these  precautions  had  been 
observed. 

Should  the  ligature  be  cut  short,  or  left  out  of  the  lower  angle  of 
the  wound?  Dr.  McDowell,  in  his  first  operation,  tied  the  pedicle 
with  a  strong  ligature,  and  left  the  end  hanging  out  of  the  wound, 
and,  before  we  learned  how  to  use  antiseptics,  I  have  no  doubt  that 
was  the  best  way  to  use  the  ligature,  as  it  kept  the  wound  open  and 
acted  as  a  means  of  drainage.  But  such  use  of  the  ligature  is  incom- 
patible with  antiseptic  treatment,  for  the  reason  that  it  permits  the 
ingress  of  septic  particles.  There  can  be  no  question  that,  as  the 
operation  is  now  done  antiseptically,  we  ought  always  to  cut  the  liga- 
ture short,  return  the  pedicle  carefully  to  its  proper  place,  and  close 
the  wound  as  completely  as  possible. 

Drainage. 

Drainage  is  a  question  of  much  importance  in  ovariotomy,  and  in 
speaking  of  the  subject  it  is  well  to  consider  it  in  two  divisions,  primary 
and  secondary. 

By  primary  I  mean  its  employment  at  the  time  of  the  operation, 
and,  by  secondary,  the  establishment  of  drainage  any  time  during  the 
after  treatment.  The  two  conditions  for  which  I  have  employed 
primary  drainage  are,  first,  peritoneal  dropsy,  and,  second,  cases  in 
which  we  have  been  obliged  to  separate  extensive  and  numerous 
adhesions.  From  these  surfaces  we  are  almost  certain  to  have  sero- 
sanguinous  effusions,  sometimes  in  considerable  quantities.  For  the 
ascitic  collection  drainage  is  quite  effectual.  If  the  peritoneal  mem- 
brane is  not  too  much  diseased  we  may  expect  that  the  cavity  of  the 
abdomen  may  be  kept  empty  until  a  change  in  it  causes  a  cessation 
of  the  effusion.  When,  as  not  infrequently  is  the  case,  there  is  an 
element  of  malignancy  in  the  growth,  the  ascites  will  continue  and 
add  greatl^y  to  the  exhausting  influence  of  the  disease.  Of  course  the 
cases  in  which  drainage  is  necessary  are  those  of  great  accumulation, 
and  not  when  the  quantity  is  small. 

In  the  second  class  of  cases  drainage  has  a  very  restricted  if  not 
doubtful  place.  Experience  must  determine  the  question,  in  what 
cases  is  it  useful.  The  tube  does  not  permit  the  passage  of  blood  to 
any  extent.  When  blood  is  extravasated  in  the  abdominal  cavity  it 
coagulates  and  will  not  enter  the  tube,  but  remains,  and  I  think  often 
without  doing  harm.  The  serum  set  free  by  its  separation  from  the 
coagulum  if  present  in  considerable  quantities  may  for  the  first  forty- 
eight  hours  find  its  way  through  the  tube.  Very  soon,  however,  the 
fibrin  in  the  serum  coagulates  about  the  tube  forming  an  envelope 
that  prevents  the  passage  of  anything.     This  is  about  what  happens 


DRAINAGE.  751 

in  drainage,  and  in  most  cases  where  it  seems  indicated  is  of  doubtful 
utility.  We  may  well  ask  whether  closing  the  abdomen  antiseptically 
when  we  expect  some  effusion  is  not  better  than  to  leave  an  opening 
with  a  tube  in  it  that  it  is  difficult  if  not  impossible  to  keep  free  from 
sepsis.  I  think  rubber  makes  the  most  reliable,  manageable,  and  use- 
ful drainage  tube.  When  prepared  for  use  it  is  about  three-eighths  of 
an  inch  in  diameter  and  four  feet  long,  and  the  end  to  be  inserted  has 
a  number  of  openings  for  about  three  inches.  The  perforated  ex- 
tremity should  be  conducted  by  the  fingers  into  the  bottom  of  the 
retro-uterine  pouch,  and  where  the  tube  passes  out  of  the  wound  it 
may  be  caught  by  the  stitch  in  the  lower  angle  of  the  wound  to  pre- 
vent it  from  slipping  out.  The  free  extremity  of  the  tube  is  brought 
over  the  edge  of  the  bed  and  placed  in  a  jar  full  of  a  five  per  cent, 
solution  of  carbolic  acid.  By  placing  the  dressing  close  around  the 
tube  we  can  pretty  certainly  exclude  germs  in  that  way,  and  they  are 
prevented  from  entering  the  tube  because  it  is  submerged  in  the  car- 
bolic water.  A  more  commonly  used  drain  is  a  straight  or  slightly 
curved  glass  tube  with  openings  in  the  sides  or  end  of  it.  It  is  about 
six  inches  long  and  has  a  lip  to  prevent  its  slipping  into  the  abdominal 
cavity.  The  perforated  portion  is  passed  down  behind  the  uterus  and 
the  other  end  extends  through  the  wound.  A  sponge  saturated  with 
an  antiseptic  closely  embraces  the  external  end  of  the  tube  and  the 
dressings  are  applied  as  usual. 

The  object  of  secondary  drainage  is  to  evacuate  fluids  that  are  caus- 
-  ing  septic  symptoms.  When  the  patient  manifests  decided  symptoms 
of  septicaemia  there  is  a  strong  probability,  indeed  almost  a  certainty, 
that  there  is  decomposing  fluid  in  the  peritoneal  cavity,  and  that  its 
evacuation  will  greatly  improve  the  chances  of  recovery.  The  putrid 
material  is  generally  in  the  cut  de  sac,  and  sometimes  may  be  discovered 
by  an  examination  through  the  vagina.  We  can  frequently  reach  and 
remove  this  fluid  by  opening  the  posterior  wall  of  the  vagina  and 
washing  the  pelvis  out  by  simply  throwing  a  stream  of  warm  water 
that  has  been  boiled  to  purify  it,  through  the  opening.  The  intention 
should  be  to  wash  out  the  pelvic  cavity  only.  A  drainage  tube  may 
be  left  in  the  opening  for  two  or  three  days  to  facilitate  the  escape  of 
such  fluids  as  may  not  have  been  washed  away. 

I  am  not  prepared  to  advise  the  injection  of  mercurial  or  carbolic 
acid  solutions  into  the  peritoneal  cavity,  believing  that  if  they  are 
strong  enough  to  be  germicidal  they  are  harmful ;  and  if  not  of  that 
strength  they  are  of  little  use.  In  desperate  cases  the  life  of  patients 
have  apparently  been  saved  by  reopening  the  incision  and  washing 
out  the  abdominal  cavity  with  warm  water  and  closing  it  up  again. 
There  is  not  much  risk  in  doing  this  operation  in  the  class  of  cases  to 
which  it  is  applicable,  as  their  condition  can  scarcely  be  made  worse 
by  it. 


CHAPTER    XLV. 

ABDOMINAL  OVARIOTOMY   {Continued). 

Before  describing  ovariotomy,  I  propose  considering  some  of  the 
more  important  conditions  presenting  themselves  to  us,  and  which 
often  embarrass  the  experienced  operator. 

We  should  regard  inflammation  in  the  tumor,  whether  the  tumor 
be  large  or  small,  with  or  without  suppuration,  as  an  indication  for 
immediate  operation,  as  the  risks  of  the  inflammation  are  very  great, 
and  are  probably  lessened  by  the  removal  of  the  tumor.  This  is 
especially  the  case  if  the  inflammation  is  attended  with  hectic  symp- 
toms. 

Although  rupture  of  the  cyst  and  effusion  into  the  peritoneal  cavity 
is  not  always  attended  with  grave  symptoms,  yet  the  supervention  of 
peritonitis  to  a  serious  degree,  or  septicaemia  which  threatens  life  or 
the  general  welfare  of  the  patient,  demands  the  operation  for  the 
removal  of  the  tumor,  large  or  small,  and  drainage  of  the  peritoneal 
cavity. 

Pregnancy  neither  absolutely  contraindicates  nor  demands  ovari- 
otomy. Unless  there  is  very  injurious  pressure  from  distension,  the 
operation  is  not  demanded,  and  we  should  wait  for  that  condition 
before  we  determine  to  interfere  in  any  way.  When  dangerous  pres- 
sure does  occur,  if  the  tumor  is  multilocular  to  such  a  degree  as  to 
make  it  impossible  to  remove  any  considerable  quantity  of  the  fluid 
by  tapping,  the  choice  lies  between  evacuating  the  uterus  and  remov- 
ing the  tumor.  Dr.  Barnes  is  in  favor  of  inducing  abortion  first, 
and  removing  the  tumor  after  the  patient  recovers  from  this  operation, 
and  the  symptoms  require  it ;  while  Mr.  Wells  advocates  and  prac- 
tices the  removal  of  the  tumor,  and  a  nunber  of  successful  cases  attest 
the  soundness  of  his  judgment.  If,  however,  the  tumor  is  oligocystic, 
or  presents  a  large  sac  from  which  a  great  quantity  of  fluid  may  be 
removed,  and  much  room  thus  gained,  the  tumor  ma}^  be  +apped  once 
or  several  times  until  gestation  is  completed.  I  have  in  this  way 
treated  two  cases,  in  which  gestation  went  on  to  term,  and  the  patients 
gave  birth  to  living,  healthy  children.  From  one  of  these  I  removed 
the  tumor  six  months  after  the  child  was  born ;  the  other,  although 
the  child  is  nearly  a  year  old,  is  still  carrying  her  tumor  with  compara- 
tive comfort. 

Sometimes  errors  or  carelessness  in  diagnosis  lead  us  into  mistakes 
of  so  grave  a  character  as  to  call  for  unexpected  resources.  One  of 
them  is  the  unsuspected  coexistence  of  pregnancy  and  ovarian  tumor, 


PEEGNANCY   WITH    THE   TUMOE.  753 

and  the  wounding  of  the  gravid  uterus  during  the  operation.  I  have 
collected  the  following  cases  as  illustrative  of  the  proper  method  of 
managing  them. 

The  rarity  of  this  class  of  cases,  and  the  interest  attached  to  them 
in  a  diagnostic  and  therapeutic  sense,  leads  me  to  report  the  following 
case  of  my  own,  and  to  present  all  I  can  find  of  a  similar  character :  * 

A  physician  from  a  neighboring  city  visited  Chicago,  accompanied 
by  a  patient,  to  consult  me  about  an  ovarian  tumor.  The  physician  is 
a  man  of  the  highest  standing  in  the  profession,  and  of  unquestionable 
integrity  and  honor. 

The  tumor  had  been  first  noticed  about  one  year  previous  to  my 
seeing  the  patient,  and  had  grown  more  rapidly  in  the  last  six  months. 
The  diagnosis  given  by  the  doctor  was  easily  verified,  viz.,  an  ovarian 
tumor,  most  likely  originating  in  the  left  ovary,  and  probably  mono- 
cystic  in  character.  The  patient  was  an  unmarried  lady,  twenty-three 
years  of  age,  very  modest  in  her  demeanor,  and,  as  I  was  assured  by 
friends,  of  unblemished  reputation.  The  cessation  of  the  menses  had 
occured  at  an  uncertain  period,  expressed  by  the  term  "several  months 
since."  Before  visiting  the  city,  her  physician  had  proposed  a  vaginal 
examination,  as  one  of  the  means  of  adding  certainty  to  the  diagnosis ; 
but  the  patient  begged  so  hard  to  be  spared  from  what  she  regarded 
as  a  humiliation,  that  he  was  induced  to  yield  to  her  wish.  When  I 
investigated  the  case,  she  shrank  from  it  with  much  earnestness,  and 
very  plausibly  contended  that  it  could  not  be  necessary,  as  neither  of 
us  seemed  to  have  any  doubt  as  to  the  presence  and  nature  of  the  tu- 
mor ;  consequently  I,  too,  omitted  this  important  means  of  diagnosis. 
At  this  interview  it  was  determined  that  an  operation  could  not  be  long 
postponed,  and  that,  as  soon  as  arrangements  could  be  made,  I  should 
remove  it  at  her  own  home. 

Accordingly,  in  about  two  weeks,  I  was  informed  that  everything 
was  in  readiness,  and  the  patient  desired  to  be  relieved  at  once.  Upon 
m}'  arrival,  I  met  four  physicians,  besides  the  attendant,  and  in  their 
presence  another  careful  examination  was  made,  and  as  before,  and  for 
the  same  reasons,  vaginal  exploration  was  dispensed  with.  All,  how- 
ever, seemed  perfectly  satisfied  with  the  correctness  of  the  diagnosis, 
and  the  necessity  of  an  operation  for  the  removal  of  the  tumor. 

Preparations  were  at  once  perfected,  the  patient  etherized,  i:»laced 
upon  the  table,  and  an  incision  about  three  inches  long  in  the  linea 
alba  exposed  the  sac.  After  assuring  myself  that  there  were  no  ad- 
hesions on  the  anterior  surface,  I  introduced  Spencer  Wells's  trocar, 
and  drew  off  about  twelve  quarts  of  an  amber-colored  fluid.  The 
fluid  was  thin,  but  somewhat  viscid,  presenting  the  appearance  I  had 
often  witnessed  in  ovarian  tumors.     When  the  sac,  was  nearly  emptied 

*  From  American  Obstetrical  Journal. 
48 


754  ABDOMINAL   OVARIOTOMY, 

I  noticed  a  tumor  behind  it,  adhering  to  the  sac  and  preventing  it 
from  passing  out  through  the  incision.  The  second  tumor  was  elastic, 
and  so  perfectl}^  resembled  a  secondary  cyst  that  I  had  no  hesitation  in 
plunging  the  trocar  through  its  walls,  with  a  view  still  further  to 
lessen  the  bulk  of  the  entire  mass  by  evacuating  its  contents.  As 
the  trocar  met  with  unusual  resistance,  and  nothing  but  blood  passed 
through  it,  I  became  convinced  that  there  was  something  unusual 
about  it.  The  incision  was  somewhat  enlarged,  and  as  much  of  the 
emptied  sac  drawn  out  as  would  pass,  when  it  was  discovered  that 
slight  adhesions,  and  not  continuity  of  tissue,  connected  the  two. 
After  the  cyst  was  entirely  withdrawn,  I  was  astonished  to  find  that 
the  second  tumor  was  the  impregnated  uterus,  and,  still  worse,  that 
it  was  wounded  and  bleeding.  This  revelation  was  accepted  with 
many  doubts  by  the  physicians  present,  who  were  the  friends  and 
neighbors  of  the  patient,  and  believed  it  impossible  that  she  should 
be  pregnant.  The  facts  were  so  patent,  however,  as  soon  to  overcome 
their  incredulity. 

At  that  moment  I  did  not  call  to  mind  an  almost  precisely  similar 
instance  that  had  occurred  to  Mr.  Wells,  and  could  not  recall  a  prece- 
dent for  my  guidance.  The  wound  in  the  uterus  had  been  very  nmch 
enlarged  by  the  contraction  of  the  transverse,  oblique,  and  longitudi- 
nal fibres  of  that  organ,  until,  in  the  few  moments  that  had  elapsed 
since  the  puncture,  it  had  become  as  large  as  a  silver  dollar.  It 
seemed  to  me,  in  the  short  time  I  had  for  reflection,  that  the  only 
way  out  of  the  difficulty  was  to  evacuate  the  uterus.  This  was  done 
by  making  an  incision  about  four  inches  long  from  near  the  fundus 
downwards,  so  as  to  include  the  accidental  aperture.  The  incision 
exposed  the  placenta  at  about  the  middle  of  its  attachment.  This 
organ  was  easily  and  rapidly  separated  by  passing  the  index  finger 
between  it  and  the  uterine  walls,  and  completely  removed.  After 
this  was  done,  the  right  side  of  the  foetus,  the  arm,  hip,  and  feet  were 
perfectly  exposed.  The  breech  was  seized  and  drawn  towards  the 
opening,  when  the  foetus  was  expelled  by  uterine  contraction.  The 
membranes  and  liquor  amnii  were  next  removed,  when  the  uterus 
was  perfectly  devoid  of  all  its  former  contents. 

Gestation  had  advanced  to  about  the  middle  of  the  seventh  month. 
The  foetus  evinced  no  signs  of  life  after  its  removal,  and  had  doubt- 
less died  from  the  effect  of  hemorrhage  from  the  wounded  placenta. 

The  incision  in  the  uterus  was  closed  by  interrupted  sutures  of  fine 
silk,  including  the  visceral  peritoneum,  the  whole  of  the  muscular 
wall,  and  the  mucous  membrane.  The  sutures  were  cut  short,  and 
no  provision  made  for  their  removal.  By  the  time  the  sutures  were 
all  inserted  and  tied,  the  uterus  had  contracted  very  firml3^ 

Thanks  to  the  valuable  aid  afforded  me  by  the  gentlemen  present 
(whose  names  for  obvious  reasons  I  dare  not  mention)  neither  blood. 


PEEGNANCY   WITH   THE   TUMOR.  755 

nor  amniotic  nor  ovarian  fluids  had  found  their  way  into  the  peri- 
toneal cavity. 

In  order  to  secure  a  free  exit  of  the  lochia  from  the  cavity  of  the 
uterus,  and  thus  prevent  the  danger  of  its  passing  through  the  wound, 
the  OS  uteri  was  freely  dilated  with  the  finger,  and  a  long  flexible 
catheter  left  in  it  some  hours.  The  pedicle  of  the  ovarian  cyst  was 
tied  with  a  double  ligature  of  plaited  silk,  and  returned  into  the  ab- 
dominal cavity.  The  ligatures  were  brought  out  at  the  lower  angle 
of  the  wound,  and  left  long  enough  to  hang  down  between  the 
thighs.  The  wound  in  the  abdomen  was  closed  by  interrupted 
sutures,  and  dressed  with  a  thick  layer  of  carbolized  cotton  batting. 
The  only  interest  connected  with  the  future  progress  of  the  case  is, 
that  there  was  not  a  disagreeable  symptom,  except  a  few  trivial  after- 
pains. 

After  the  operation  was  concluded,  I  was  consoled  for  my  error  in 
not  making  a  vaginal  examination,  and  consequent  ignorance  of  the 
complicating  pregnancy,  by  the  assurance  of  all  the  gentlemen  who 
assisted  me,  that  their  confidence  in  the  chastity  of  the  patient  was 
equal  to  their  reliance  upon  the  faithfulness  of  their  own  wives,  and 
that  a  suspicion  of  her  purity  would  not  be  entertained  by  any  one 
who  was  acquainted  with  her.  Her  complete  recovery,  however, 
and  up  to  the  present  time  her  own  entire  ignorance  that  a  foetus  had 
been  removed  with  the  tumor,  together  with  the  preservation  of  her 
reputation,  which  could  not  have  been  done  by  any  other  course, 
fully  compensates  me  for  the  chagrin  I  felt  for  all  my  shortcomings 
in  the  case. 

I  have  purposely  omitted  names,  dates,  and  places,  to  avoid  the 
possibility  of  identification  of  the  patient ;  I  am  persuaded,  however, 
that  this  will  not  detract  from  the  interest  of  the  case. 

As  the  subject  and  manner  of  closing  the  wound  in  the  operations 
for  gastro-hysterotomy  is  now  under  discussion,  I  would  call  atten- 
tion to  this  part  of  the  procedure.  The  entire  absence  of  septic  or 
inflammatory  symptoms,  I  think,  gives  evidence  that  there  was  no 
escape  of  blood  from  the  edges  of  the  wound,  or  from  the  uterine 
cavity  into  the  peritoneal  sac,  and  warrants  us  in  assuming  that  the 
closure  by  sutures  was  judicious,  if  not  the  all-important  condition  of 
success.  After  the  operation,  it  was  quite  apparent  that  a  great 
change  must  take  place  in  the  relation  of  the  edges  of  the  incision  in 
the  uterus,  to  allow  the  least  drainage  into  the  peritoneal  cavity. 

The  frequent  occurrence  of  pregnancy  during  the  growth  of  ovarian 
tumors  is  recognized  by  all  experienced  ovariotomists,  and  is  a  subject 
for  consideration  in  all  instances  where  a  diagnosis  is  to  be  made 
preparatory  to  the  removal  of  the  tumor.  Under  ordinary  circum- 
stances, the  diagnosis  of  this  complication  is  not  very  difficult,  as  the 
uterus  lies  anterior  to  or  on  one  side  of  the  tumor,  so  that  its  presence 


756  ABDOMINAL    OVARIOTOMY. 

and  contents  are  easily  ascertained,  but  exceptional  cases  are  some- 
times found  when  the  difficulties  are  sufficient  to  mislead  an  ex- 
perienced and  accomplished  observer.  Mr.  Wells  acknowledges  mis- 
takes in  his  own  practice,  and  mentions  the  fact  that  Dr.  J.  Marion 
Sims  fell  into  an  error  of  diagnosis  and  did  not  discover  the  compli- 
cation until  the  gravid  uterus  was  exposed  during  the  operation  for 
the  extirpation  of  the  ovarian  tumor.  A  considerable  number  of 
other  cases  might  be  cited  in  which  mistakes  of  this  kind  have 
occurred.  The  probabilities  are  that  more  of  these  errors  arise  from 
insufficient  scrutiny  in  cases  where  the  diagnosis  might  be  made,  than 
from  an  entire  impossibility  to  ascertain  the  true  state  of  things. 
Our  improved  methods  of  examination,  and  more  perfect  knowledge 
in  interpreting  the  phenomena  of  pregnancy,  ought  to  secure  us 
against  errors  of  this  kind  in  all  but  the  very  rarest  combination  of 
circumstances. 

As  the  known  cases  in  which  the  double  operation  of  ovariotomy 
and  hysterotomy  has  been  performed  are  very  few,  I  have  collected 
all  I  could  find  with  my  limited  means  of  research,  and  will  not 
apologize  for  reproducing  them  in  a  condensed  form  in  this  connec- 
tion. 

Mr.  Wells  publishes  a  case,  alluded  to  above,  in  his  well-known 
work  on  Diseases  of  the  Ovaries,  almost  exactly  like  the  one  I  have 
recorded.  It  was  first  reported  in  the  Medical  Times  and  Gazette  of 
September  30th,  1865. 

He  had  entirely  overlooked  the  existence  of  pregnancy  with  ova- 
rian disease,  and  after  removing  an  adherent  multilocular  cyst  of 
the  left  ovary,  he  felt  what  he  thought  was  a  cyst  of  the  right  ovary, 
— tapped  it,  and  then  found  it  was  the  gravid  uterus.  From  this 
puncture  two  or  three  pints  of  bloody  fluid  escaped  through  the 
canula,  when  the  tumor  became  much  less  tense ;  and  he  says  on 
raising  the  tumor  up,  he  saw  the  Fallopian  tube  passing  from  its 
upper  part,  and  thus  he  knew  at  once  he  had  punctured  the  uterus. 
He  says: 

"  On  withdrawing  the  camila,  a  soft,  spongy,  bleeding  mass  protruded,  and  on  putting 
in  my  finger  to  push  this  back  and  examine  the  uterine  cavity,  the  anterior  wall  of  the 
uterus,  which  was  very  soft  and  friable,  as  it  had  undergone  fatty  degeneration,  gave 
way  along  the  middle  line  from  the  puncture  (which  was  near  the  fundus)  for  an  ex- 
tent of  from  three  to  four  inches  down  the  body  toward  the  neck.  With  very  slight 
pressure  a  quantity  of  liquor  amnii  and  a  foetus  of  about  five  months  escaped.  I  then 
easily  peeled  off  the  placenta  from  the  inner  surface  of  the  uterus  ;  the  organ  did  not 
contract,  and  there  was  free  bleeding  from  three  vessels  close  beneath  the  peritoneum 
at  the  lower  angle  of  the  rupture  in  the  uterus.  These  vessels  were  secured  by  three 
silk  ligatures.  Oozing  still  going  on  from  the  surface  wiiere  the  placenta  was  attached, 
I  made  a  free  opening  into  the  vagina  by  passing  my  finger  from  above  through  the 
cervix  and  os,  and  then  put  a  piece  of  ice  into  the  uterus  and  held  it  within  by  firmly 
rasping  the  organ,  which  then  contracted.     I  then  brought  the  peritoneal  edges  of 


PREGNANCY  WITH  THE  TUMOR.  757 

the  tear  in  the  litems  together  by  an  uninterrupted  suture  of  fine  silk,  one  long  end  of 
which  I  had  previously  passed  into  the  uterine  cavity  and  out  through  the  os  into  the 
vagina.  By  seven  or  eight  points  the  edges  were  brought  accurately  together,  and 
the  other  end  of  the  silk  was  brought  through  the  opening  in  the  abdominal  wall,  with 
the  ends  of  the  three  ligatures  on  the  vessels  in  the  uterine  wall  close  to  the  pedicle, 
and  were  tied  to  the  clamp." 

The  patient  completely  recovered. 

I  am  indebted  to  Dr.  Muncle  for  the  following  very  interesting 
case,  published  in  the  Australian  Medical  Journal^  of  February,  1875, 
by  Thomas  Hillas,  M.R.C.S.,  Eng.,  of  Victoria,  Australia : 

"Mary  McC,  aged  twenty-four  years,  single,  was  admitted  to  the  Ballarat  District 
Hospital,  June  4th,  1872.  The  history  of  her  case  was  peculiar.  She  believed  that 
she  became  pregnant  in  March,  1871,  and,  not  wishing  to  be  confined  in  the  district  in 
which  she  lived,  she  sought  admission  to  the  lying-in  ward  of  the  Ballarat  Benevolent 
Asylum.  She  was  admitted  there  in  November,  1871,  and  after  staying  there  until 
the  following  June,  a  consultation  of  the  honorary  staff"  was  called,  and  she  was  dis- 
charged, her  case  being  deemed  ovarian  dropsy,  and  not  pregnancy.  On  her  admis- 
sion to  the  hospital  she  was  examined  by  the  resident  surgeon,  and  subsequently  by 
the  honorary  surgical  and  medical  staff,  all  agreeing  that  she  was  suflering  from  ova- 
rian dropsy,  and  that  it  was  a  suitable  case  for  operation.  On  June  13th,  assisted  by 
the  honorary  surgeons,  Messrs.  Nicholson  and  Whitcomb,  and  the  resident  surgeon, 
Mr.  Owen,  and  the  honorary  medical  staff,  the  patient  being  under  chloroform,  I  com- 
menced the  operation,  by  an  incision  midway  between  the  umbilicus  and  pubes.  On 
arriving  at  the  peritoneum,  I  made  a  small  opening  into  it,  when  out  spurted  a  large 
jet  of  venous  blood,  which  the  pressure  of  the  finger  controlled.  I  came  to  the  con- 
clusion tliat  I  had  wounded,  unwittingly,  a  gravid  uterus,  and,  feeling  sure  of  this,  1 
extended  the  first  incision  upward  to  the  umbilicus,  when  a  large  uterus  rolled  out  on 
to  the  thighs,  and  the  ovarian  sac  protruded.  This  was  tapped,  and  about  eleven 
quarts  of  fluid  were  drawn  ofT;  there  were  but  few  adliesions,.  which  were  easily  broken 
down,  and  there  was  no  hemorrhage.  The  sac  contained  about  a  dozen  small  cysts, 
but,  the  external  wound  being  large,  there  was  no  occasion  to  tap  them.  The  pedicle 
was  short  and  thick,  and,  after  being  tied  firmly  with  a  double  whipcord  ligature,  the 
clamp  was  securely  applied,  and  the  pedicle  divided,  the  ends  of  the  double  lig-ature 
being  tied  over  the  ends  of  the  clamp.  Now  came  the  difficulty.  The  uterus  was  all 
this  time  lying  on  the  thighs,  with  the  foetus  in  it,  and  a  wound  through  its  muscles, 
probably  into  the  placenta.  Some  of  the  bystanders  advised  that  the  wound  in  the 
uterus  should  be  sewn  up,  and  that  organ  replaced  in  the  abdomen  ;  but  seeing  that 
labor  must  come  on  soon,  and  that  the  rupture  of  the  uterus  would  most  likely  occur 
at  the  seat  of  injury,  I  personally  decided  to  perform  the  Csesarean  operation  as  being 
the  most  likely  means  of  giving  the  patient  a  chance  to  recover.  The  uterus  was  in- 
cised to  about  five  inches,  and  the  placenta  and  a  foetus,  alive  and  well  developed,  at 
about  the  eight  month  of  gestation,  extracted.  I  then  stitched  up  the  wound  in  the 
uterus  with  about  nine  or  ten  silver-wire  sutures,  carefully  tucking  the  cut  ends  down 
into  the  incision.  Immediately  on  completing  this  the  uterus  contracted  firmly.  I 
then  sewed  up  the  wound  in  the  abdomen  with  deep  and  superficial  stitches,  the  deep 
stitches  including  the  peritoneum,  leaving  the  clamp  at  the  lower  margin  of  the  wound, 
and  a  good  deal  dragged  upon.  The  right  ovary  was  the  one  affected,  and  the  patient 
measured  sixty  inches  around  the  abdomen  before  the  operation.  The  sac  and  its  con- 
tents, after  removal,  weighed  thirteen  pounds,  and  are  preserved  in  the  hospital  dis- 


758  ABDOMINAL   OVARIOTOMY. 

pensary.  The  patient  vomited  for  about  forty-eight  hours  after  the  operation,  having 
been  an 'hour  under  chloroform.  This  was  relieved  by  morphia  and  ice,  and  on  the 
fourth  day  all  unfavorable  symptoms  abated.  There  was  a  discharge  of  pus  from  the 
lower  portion  of  the  wound,  which  ceased  in  about  a  fortnight,  and  then  completely 
healed.  She  was  discharged,  cured,  at  the  end  of  six  weeks.  On  July  3d,  a  month 
after  the  operation,  she  menstruated  moderately  for  four  days,  and  again  on  the  28th 
of  August.     I  have  seen  her  several  times  since,  and  she  is  in  perfect  health." 

Dr.  Munde  also  kindly  sent  me  the  following  three  cases  which, 
although  not  exactly  corresponding  to  the  cases  already  reported, 
will  doubtless  be  of  interest  in  this  connection.  The  chances  of 
saving  the  lives  of  the  patients  would  undoubtedly  have  been  in- 
creased if  the  operator  had,  in  the  first  case,  removed  foetus  and 
tumor,  instead  of  leaving  both  untouched  ;  and  in  the  second,  the 
tumor  as  well  as  the  child.  They  will  serve  as  a  warning  to  others 
not  to  commit  the  same  error  : 

"Dr.  Erskine  Mason  reported  to  the  New  York  Pathological  Society  in  1877  the 
case  of  a  patient,  thirty  years  of  age,  single,  who  entered  Roosevelt  Hospital,  July 
30th,  1877.  Since  eighteen  months  increase  of  abdomen,  the  circumference  of  which 
at  umbilicus  measured  thirty-nine  inches.  A  vaginal  examination  showed  the  uterus 
high  in  the  pelvis  and  movable.  Distinct  fluctuation  in  abdomen ;  area  of  flatness  not 
changed  by  position  of  patient.  Diagnosis  of  ovarian  cyst  confirmed  by  one  of  the 
most  expert  ovariotomists  of  New  York  city.  Ovariotomy  was  considered  indicated. 
On  opening  the  abdomen  a  cyst  appeared,  which  was  opened  by  the  trocar,  and  eight 
ounces  of  fluid  evacuated,  when  this  cyst  was  found  to  be  the  pregnant  uterus.  The 
trocar  wound  was  closed  by  sutures,  and  the  abdominal  wound  also  united.  Patient 
gave  birth  the  next  day  to  a  six  months'  foetus.  Death  of  collapse  eighteen  and  a 
half  hours  after  operation.  Autopsy  showed  large  multilocular  cyst  of  left  ovary. 
Uterus  well  contracted  ;  no  peritonitis." 

Of  the  second  case,  Dr.  Munde  says  : 

"  I  have  looked  over  Olshausen's  recent  work  on  Diseases  of  the  Ovaries,  and  found 
mention  of  only  one  case  of  Csesarean  section  complicated  with  the  presence  of  an 
ovarian  tumor.  The  operator  was  Kob,  of  Stolp,  in  North  Germany  ;  the  original 
article  appeared  in  the  Transactions  of  ihe  Berlin  Obstetrical  Society  for  1873;  Beitrdge 
!zixr  (JeburtshUlfe  und  Gyndkologie,  vol,  ii.,  p.  99.  I  have  this  work,  and  abstract  the 
case  briefly,  as  follows  : 

'"Patient  forty  years  ;  had  four  children  ;  pregnant  near  term  with  fifth.  Found 
pelvis  occupied  by  a  dense,  fluctuating  tumor,  preventing  entrance  of  the  head.  The 
patient  was  much  debilitated  by  this  presumably  ovarian  growth.  Finding  the  passage 
of  the  child  iojpossible  through  the  normal  pelvis,  the  tumor  was  punctured  per 
vaginam,  but  only  thick  colloid  mucus  flowed  out  in  small  quantities,  even  after  enlarge- 
ment of  the  puncture  with  the  bistoury.  Finally  the  Caesarean  section  was  performed, 
the  child  extracted  alive  and  continued  to  live.  The  wound  was  closed  by  thread 
sutures,  and  death'  followed  on  the  third  day,  probably  from  septic  peritonitis.  The 
cvst  was  not  removed,  although  special  mention  is  not  made  of  the  necessity  (the  author 
probably  looked  upon  it  as  malignant,  as  colloid  tumors  were  formerly  so  regarded, 
and,  therefore,  thought  its  removal  superfluous) ;  but  he  states  that,  after  the  operation, 
colloid  matter  still  escaped  from  the  vaginal  puncture.  The  operation  was  performed 
January  17lh,  1873." 


PREGNANCY    WITH    THE    TUMOR.  759 

The  third  case  was  reported  by  Professor  Lahs,  of  Marburg,  in 
the  Deutsche  Med.  Wochenschrift,  February  2d,  1878 : 

"  L.  was  called  to  a  pliirijiara  in  labor  presumably  eight  days  ;  found  abdomen  much 
enlarged,  fluctuation  all  over  ;  firmly  adherent  cyst  of  left  ovary  filling  pelvic  cavity 
and  obstructing  delivery.  Csesarean  section ;  three  silk  sutures  in  uterus ;  cyst  too 
firmly  adherent  to  be  removable.     Death  from  collapse  in  twenty-four  hours." 

In  this  case  no  blame  can  be  attached  to  the  operator  for  not  re- 
moving the  tumor,  the  firm  adherence  of  which  to  the  pelvic  cavity, 
and  the  prostration  of  the  patient  from  her  long  labor,  rendering  so 
severe  an  undertaking  unjustifiable. 

Mr.  Wells  says,  with  reference  to  the  question  : 

"  What  should  be  done  when  a  pregnant  uterus  is  discovered  during  some  stage  of 

ovariotomy  ?     Let  it  alone But  supposing  the  operator  has  penetrated  the 

uterus  or  wounded  it?  If  any  conclusion  can  be  drawn  from  the  case  in  which  I  made 
this  mistake,  and  emptied  the  uterus,  and  two  other  cases,  in  which  the  same  mistake 
was  made  by  other  surgeons  who  did  not  empty  the  uterus,  but  closed  the  puncture  in 
its  walls  by  wire  sutures,  and  both  patients  died  after  aborting,  while  mine  recovered, 
it  would  seem  to  be  the  safer  practice  to  empty  the  uterus." 

The  soundness  of  this  teaching  must  receive  the  sanction  of  com- 
mon-sense, and  is  happily  confirmed  by  the  result  of  the  two  addi- 
tional cases,  one  published  by  Mr.  Thomas  Hillas,  of  Victoria,  and 
the  present  one  by  himself.  It  will  also  be  noticed  that  the  treatment 
of  the  wound  in  the  uterus,  and  the  manner  of  closing  the  incision  in 
that  organ,  had  an  important  bearing  on  the  subject  in  all  three  of 
these  successful  cases.  Mr.  Hillas  closed  the  wound  with  interrupted 
silver  sutures,  Mr.  Wells  with  an  uninterrupted  silk  suture,  while  mine 
was  closed  with  interrupted  silk  sutures.  From  what  I  could  see  of 
the  more  immediate  effect,  as  well  as  from  the  final  result,  I  cannot 
doubt  that  this  procedure  had  much  to  do  with  the  recovery  of  my 
case.  Although  Mr.  Hillas  makes  no  mention  of  his  having  secured 
a  free  exit  for  the  discharge  from  the  uterus  by  dilating  the  cervix,  it 
is  to  be  presumed  that  he  did  not  neglect  this  precaution.  Mr.  Wells 
passed  his  finger  down  from  the  cavity  through  the  cervix  and  os, 
while  in  my  case  I  opened  the  cervical  cavity  with  a  large  catheter. 
I  think  it  is  but  fair  to  state  that  while  these  three  cases  were  treated 
so  essentially  alike  by  all  of  the  operators,  neither  of  them  was  aware 
that  there  was  any  precedent  for  it.  I  certainly  did  not  remember 
Mr.  Wells's  case  at  the  time  I  operated,  and  I  believe  Mr.  Hillas,  like 
myself,  had  overlooked  it. 

Other  considerations  bearing  upon  the  question  of  ovariotomy,  as 
advanced  phthisis,  serious  organic  disease  of  the  heart  or  kidneys,  or 
malignancy  of  the  tumor,  in  all  or  any  of  these  conditions,  I  would 
refuse  to  perform  ovariotomy  and  resort  only  to  palliative  measures. 


760  ABDOMINAL   OVARIOTOMY. 

We  will  often  meet  with  cases  that  have  been  neglected  until  pres- 
sure has  impaired  the  nutritive  functions  to  such  an  extent  that  the 
recuperative  powers  of  the  patient  have  been  greatly  reduced.  In 
some  of  these  cases  we  may  improve  the  general  condition  of  the  pa- 
tient by  tapping  the  tumor  and  restoring  nutrition  by  proper  meas- 
ures. This  should  be  attempted  when  there  is  a  cyst  from  which 
we  can  reasonably  expect  to  draw  off  a  large  quantity  of  fluid.  If, 
however,  the  distension  is  caused  by  the  growth  of  a  multilocular 
tumor,  with  only  small  or  moderately  sized  cysts,  we  should  risk  the 
operation  without  loss  of  time  or  addition  of  the  risk  of  a  fruitless 
tapping. 

When  the  tumor  is  not  large,  or  has  been  reduced  by  tapping,  we 
should  resort  to  tonics,  abundant  and  nutritious  diet,  and  surround 
the  patient  with  the  best  hygienic  conditions  possible  until  her  health 
is  sufficiently  restored  to  enable  her  to  sustain  the  effects  of  the  opera- 
tion. 

There  are  mental  conditions  which  increase  the  hazard  of  an  opera- 
tion. 

When  a  patient  is  very  greatly  depressed  on  account  of  bereave- 
ment, or  other  causes  of  intense  grief,  the  indications  should  be  very 
urgent  to  justify  the  immediate  removal  of  the  tumor;  indeed,  if  it  is 
possible,  we  should  allow  sufficient  time  for  reaction  from  such  a  state 
of  depression.  I  feel  sure  that  I  lost  one  patient  because  I  could  not 
pay  sufficient  attention  to  this  condition. 

Courage  on  the  part  of  the  patient  is  an  important  item  in  assuring 
success  in  ovariotomy,  and  we  should  inspire  the  patient  with  hope 
by  every  possible  means.  The  most  favorable  view  of  her  case  should 
be  presented  to  her,  and  every  means  taken  to  help  her  to  expect 
recovery,  instead  of  leaving  doubt  in  her  mind. 

The  menstrual  cycle  affords  a  time  when  the  operation  is  more 
promising,  and  I  think  there  is  no  doubt  that  we  should  operate  as 
soon  as  the  menstrual  flow  has  subsided,  if  possible. 

The  time  of  year  in  this  climate  is  not  a  matter  of  so  much  import- 
ance as  in  warmer  latitudes. 

I  would  rather  operate  in  the  warm  than  in  the  cold  season,  as  ven- 
tilation can  be  secured  much  more  easily  at  such  times  than  during 
the  inclemency  of  the  winter  season. 

If  we  can  command  the  time,  without  serious  inconvenience  to  the 
patient  in  reference  to  the  size  of  the  tumor,  it  would  be  better  to  select 
a  period  between  the  two  extremes  of  temperature. 

The  best  place  for  the  operation,  if  the  patient  has  a  comfortable 
home,  is  at  her  private  residence  instead  of  a  hospital,  unless  it  is  one 
in  which  isolation  and  good  ventilation  can  both  be  commanded. 

A  well-organized  special  hospital,  in  consequence  of  the  good  atten- 
tion always  at  hand,  is  probably  the  next  best  place.    When  the  patient 


PREPARATION".  761 

comes  to  the  city  in  a  good  condition  for  ovariotomy  the  operation 
should  not  be  delayed  lest  the  health  of  the  patient  be  deteriorated  by 
the  urban  or  hospital  atmosphere.  If  the  operation  is  to  be  performed 
in  a  private  house,  the  room  should  be  selected  with  a  view  to  good 
ventilation,  quietude,  and  cleanliness.  Mere  convenience  is  not  a 
sufficient  reason  for  the  choice  of  rooms,  as  no  sacrifice  is  too  great  if 
it  will  insure  success. 

Preparation  of  the  Room. 

The  room  should  be  stripped  of  all  furniture  and  hangings,  the  car- 
pets and  wall-paper  be  removed,  closets  communicating  with  it  be 
emptied,  and  the  room  and  closets  thoroughly  cleansed  and  white- 
washed. After  a  complete  scrubbing  and  washing,  the  woodwork, 
including  the  floors,  ought  to  be  rubbed  with  a  solution  of  the  bichlo- 
ride of  mercury  1  to  1000  or  a  5  per  cent,  solution  of  carbolic  acid. 
The  outside  windows  and  doors  should  remain  open  until  the  room 
is  dry,  then  all  closed  and  an  iron  pot  holding  several  pounds  of  sul- 
phur placed  in  the  room  and  the  sulphur  ignited.  While  the  sulphur 
is  burning,  and  for  several  hours  after,  the  room  is  kept  closed.  It  is 
believed  that  this  process  will  disinfect  a  room  that  has  not  been  more 
than  ordinarily  exposed.  A  single  iron  bedstead,  mattress,  bedding 
two  chairs,  and  a  table,  all  new,  is  sufficient  furniture.  In  cold  wea- 
ther the  warmth  of  the  room  should  be  preserved  by  an  open  fire- 
place, and  not  by  stove  or  furnace.  If  the  room  is  not  used  immedi- 
ately after  the  preparation,  it  should  be  kept  full  of  carbolized  spray 
from  a  5  per  cent,  solution  until  ready  to  begin  the  operation. 

It  is  hardly  necessary  to  state  that  a  good,  faithful,  and  intelligent 
nurse  is  indispensable.  The  care  of  the  patient  should  not  be  com- 
mitted to  interested  relatives  unless  they  possess  the  information 
requisite  for  correct  treatment. 

Preparation. 

The  personal  supervision  of  the  patient  is  a  matter  of  the  first  im- 
portance. All  of  her  functions,  especially  those  of  the  skin,  kid- 
neys, and  alimentary  canal,  should  be  regulated,  if  they  need  regula- 
tion, before  placing  her  upon  the  table.  The  first  by  means  of  a  warm 
bath,  the  second  by  the  administration  of  some  preparation  of  lithium 
or  the  acetate  of  potassium,  and  the  third  by  the  administration  of  a 
gentle  but  thorough  cathartic ;  castor  oil  is  ordinarily  the  best.  Meas- 
ures should  be  taken  to  keep  up  the  action  of  the  skin  and  kidneys. 
The  under-garments  should  be  woollen,  and  cover  the  patient  from 
the  throat  to  the  feet,  and  enough  changes  secured  to  keep  them  clean 
and  fresh,  and  the  secretions  encouraged  by  the   administration  of 


762  ABDOMINAL    OVARIOTOMY. 

plenty  of  fluids,  of  which  cold  water  is  the  best.  The  urine  must  be 
watched  and  its  quantity  and  character  regulated. 

During  the  operation  the  patient  should  be,  as  near  as  practicable, 
covered,  her  extremities  especially,  with  her  woollen  garments. 

The  personal  preparation  of  the  surgeon,  assistants,  and  attendants 
should  be  equally  careful.  Perfect  cleanliness  in  them  is  a  matter  of 
paramount  importance ;  to  this  end,  ablution  of  the  hands  and  cleans- 
ing the  nails  must  be  thorough  immediately  preceding  the  operation. 
All  of  the  articles  used  in  the  operation  should  also  be  as  clean  as 
possible.  Every  preparation  should  be  made  that  will  conduce  to  the 
convenience  and  easy  access  to  every  part  of  the  patient  by  the  sur- 
geon and  the  assistants.  A  table  of  convenient  size,  say  five  feet  long 
and  twenty  inches  wide,  and  high  enough  to  enable  the  surgeon  to 
stand  erect,  should  be  placed  near  an  abundant  source  of  good  light, 
and  yet  so  that  all  may  pass  around  it  with  ease.  The  table  should 
be  prepared  by  covering  it  with  a  comforter  or  blanket,  and  a  pillow 
placed  on  the  end  most  remote  from  the  light. 

When  ready,  the  patient  should  be  thoroughly  etherized,  preferably 
in  bed,  and  placed  upon  the  table,  her  wrapper  drawn  up  close  under 
her  arms  to  prevent  it  from  becoming  soiled,  and  the  abdomen  covered 
with  a  rubber  blanket,  with  an  opening  eight  or  ten  inches  long,  and 
wide  enough  to  permit  of  the  exposure  of  the  most  prominent  part 
of  the  tumor. 

Operation. 

The  surgeon  may  stand  to  the  right  side  of  the  patient,  or  he  may 
cause  her  to  be  placed  near  the  end  of  the  table  nearest  the  light, 
with  her  limbs  hanging  over  the  end  of  the  table,  each  foot  resting  on 
a  stool,  and  take  his  position  at  the  foot  of  the  table. 

The  operation  may  be  divided  into  three  stages,  and  the  instruments 
necessary  to  perform  it  into  as  many  groups.  The  first  is  the  exposure 
of  the  tumor ;  second,  the  removal  of  the  same  ;  and  third,  the  cleans- 
ing of  the  peritoneal  cavity  and  closure  of  the  wound. 

All  instruments  after  thorough  cleansing  should  be  immersed  in  3 
per  cent  solution  of  carbolic  acid  and  taken  from  this  by  the  operator 
as  needed. 

For  the  first  we  need  a  scalpel,  blunt-pointed  bistoury,  scissors,  a 
grooved  director,  a  sharp  hook,  and  one  or  two  sponges  which  have 
been  thoroughly  cleaned  and  soaked  in  water  containing  five  per  cent, 
of  carbolic  acid  For  the  second  and  third,  a  large  trocar  with  rub- 
ber tube,  long  and  large  enough  to  carry  the  fluid  over  the  side  of  the 
patient  down  into  a  receptacle  under  the  table :  a  large  steel  sound, 
scissors,  forceps,  and  thread,  with  which  to  arrest  hemorrhage;  two 
large  needles,  armed  with  double-plaited  silk  ligatures,  well  waxed ; 
clamps,  wire  ecraseurs,  and  a  half-dozen  fine  sponges  that  have  never 


FIRST   STEP.  ,  763 

been  in  use,  and  thoroughly  prepared  by  cleansing  and  carbolizing, 
and  some  pieces  of  fine  soft  flannel,  one-half  yard  square;  a  half- 
dozen  long,  straight  needles,  armed  with  long  silk  ligatures,  well 
W'axed,  and  plenty  of  silk  for  tying  small  arteries ;  lint,  several  rolls 
of  cotton  batting,  and  a  binder  of  fine  flannel,  long  enough  and  large 
enough  to  cover  all  of  the  dressings.  In  addition  to  these,  there  should 
be  plenty  of  hot  and  cold  water  in  basins,  carbolized  oil,  and 
water. 

There  should  be  at  least  three  assistants :  one  to  hold  the  rubber 
cloth  and  steady  the  tumor,  who  may  stand  at  the  side  of  the  patient; 
another  to  administer  the  ether  ;  and  a  third  to  use  the  sjDonges  and 
otherwise  assist  the  operator. 

Before  the  patient  is  put  under  the  influence  of  ether,  she  should 
empty  the  bladder,  and  in  default  of  her  having  done  so,  the  catheter 
should  be  so  used. 

The  incision  is  usually  made  in  the  median  line,  midway  between 
the  umbilicus  and  the  symphysis  pubis.  The  cut  through  the  integu- 
ment should  be  from  two  and  a  half  to  three  inches  long,  and  that 
through  the  subjoined  aponeurosis  and  peritoneum  only  one  inch  in 
length.  This  is  an  exploratory  incision,  and  will  enable  us  to  deter- 
mine the  nature  of  the  tumor,  the  extent  and  firmness  of  the  adhesions, 
vascularity,  etc.,  or  whether  there  is  a  tumor  or  not. 

In  making  the  incision  we  may  cut  freely  through  the  skin  and  adi- 
pose tissue  immediately  beneath  it.  This  will  expose  the  aponeurotic 
'expansion  of  the  abdominal  muscles.  We  now,  with  a  sharp  hook, 
lift  up  a  thin  layer  of  this  aponeurosis  and  divide  it.  If  we  are  not  in 
the  median  line,  the  edge  of  the  rectus  muscle  will  come  in  view. 
When  this  is  the  case,  we  search  for  that  line  by  passing  the  grooved 
director,  or  the  handle  of  the  scalpel,  into  the  sheath,  first  to  the  right, 
then  to  the  left,  and  the  instrument  will  be  arrested  at  the  border  of 
the  muscle,  and  this  points  out  the  location  of  the  linea  alba.  By 
very  light  strokes  of  the  knife,  or  the  lifting  up  of  a  portion  of  the  ex- 
panded tendon,  we  carefully  divide  it  down  to  a  less  marked,  yet 
usually  distinct  layer  of  adipose  tissue.  This  last  is  generally  thin 
and  loose  compared  with  the  subcutaneous  stratum,  and  lies  upon  the 
peritoneum.  It  should  be  carefully  divided,  and  the  peritoneum 
brought  into  view.  Here  the  operator  pauses  until  all  hemorrhage 
ceases,  and,  if  necessary,  twists  or  ligates  small  arteries  or  veins  which 
may  bleed  too  freely.  These  steps  in  the  operation,  and  in  fact  all 
others,  should  be  taken  without  hurry,  and  the  operator  should  give 
himself  time  to  thoroughly  understand  the  anatomy  of  the  parts  with 
which  he  is  dealing. 

After  the  bleeding  has  ceased  the  peritoneum  should  be  raised  by 
the  hook,  and  divided  to  an  extent   sufficient  to  pass  the   grooved 


76-1  ABDOMIXAL    OVARIOTOMY. 

director,  upon  which  the  division  may  be  made  to  the  extent  of  the 
deep  portion  of  the  incision. 

Tliere  are  four  sources  of  possible  embarrassment  in  opening  the 
peritoneal  cavity.  The  first  and  most  common  is  the  adhesion  of  the 
parietal  to  the  visceral  layer  of  the  peritoneum  covering  the  tumor. 
This  is  more  of  an  embarrassment  than  danger,  as  the  only  harm 
likely  to  be  done  may  be  the  opening  of  the  tumor.  The  next  most 
frequent  is  the  presence  of  the  bladder  between  the  tumor  and  the 
peritoneum,  in  which  case  it  will  require  great  care  to  prevent  wound- 
ing this  viscus.  If  there  is  any  doubt  which  the  appearance  of  the 
parts  will  not  solve,  it  will  be  well  for  some  one  who  is  not  assisting 
the  operator  to  pass  the  catheter  into  that  organ.  When  the  bladder 
is  found  in  this  position  it  may  be  avoided  by  extending  the  incision 
upward  sufficiently  to  pass  above  it. 

The  third  is  the  presence  of  the  uterus  beneath  the  incision.  The 
use  of  the  sound  will  enable  us  to  diagnose  this  circumstance,  if  it 
has  not  been  done  in  the  examination  before  the  operation. 

The  fourth  is  the  presentation  of  the  intestine.  We  may  diagnose 
this  by  the  contents,  shape,  etc. 

When  the  peritoneum  is  divided  sometimes  ascitic  fluid  escapes, 
generally  small  in  quantity,  but  sometimes  copious.  We  should  now 
inspect  the  exposed  portion  of  the  tumor.  If  it  is  an  oligocyst,  or 
monocyst,  it  will  present  a  shining,  pearly  aspect,  with  very  small 
vessels  ramifying  in  its  walls.  If  it  belongs  to  the  polycystic  variety 
there  will  often  be  quite  large  vessels  noticeable ;  the  pearly  aspect 
will  be  less  marked,  and  sometimes  replaced  by  a  livid  or  red  color. 
If  it  is  a  uterine  tumor  it  will  be  of  a  dull  red  color,  thick  and  fleshy 
to  the  sense  of  touch.  Tumors  of  the  omentum,  malignant  or  other- 
wise, would  not  answer  to  this  description. 

Second  Step. 

When  satisfied  that  the  tumor  is  ovarian,  we  should  introduce  the 
steel  sound  gently  and  slowly ;  pass  it  over  the  anterior  and  lateral 
portions  of  the  tumor,  to  ascertain  whether  there  are  any  adhesions; 
if  any,  their  locality  and  firmness.  Often  there  will  be  some  so  very 
slight  that  they  will  give  Avay  as  the  sound  is  passed  over  the  tumor. 

The  force  with  which  the  sound  should  be  applied  to  these  ad- 
hesions must  be  very  slight,  as  it  is  not  advisable  to  break  up  strong 
adhesions  in  this  way. 

Should  there  be  no  adhesions  discoverable  by  the  sound,  the  pre- 
sumption is  that  there  are  none.  Upon  this  presumption  our  incision 
may  be  enlarged  to  the  size  of  the  tegumentary  opening- 

If  adhesions  are  large  and  firm,  the  whole  incision  should  be  in- 
creased until  five  inches  in  length.     I  believe  this  to  be  the  proper 


SECOXD    STEP. 


765 


time  to  extend  the  incision  to  its  required  length,  because  we  may  the 
better  prevent  the  flow  of  blood  into  the  peritoneal  cavity.  Up  to 
this  time  the  assistant  who  steadies  the  tumor  has  very  little  to  do ; 
but,  during  the  time  of  the  enlargement  of  the  incision  and  the 
removal  of  the  tumor,  he  should  keep  the  margins  of  the  wound  in 
such  close  apposition  to  the  surface  of  the  growth  that  nothing  can 
enter  the  peritoneal  cavity. 

Ovariotomy. 

The  second  step  in  the  operation  consists  in  the  removal  of  the 
tumor.     The  large  trocar,  with  a  rubber  tube  attached,  so  as  to  lead 

Fig.  299. 


Fitch's  Trocar. 

the  fluid  into  a  vessel  under  the  table,  may  now  be  plunged  into  the 
cyst  at  the  upper  angle  of  the  wound,  and  so  much  of  the  contents  of 
the  tumor  as  will  pass  through  the  tube  be  drawn  off. 

As  the  tumor  decreases  in  size  the  sac  should  be  seized  by  hooks, 
the  trocar  or  forceps,  or  both,  as  may  be  necessary,  and  drawn  for- 
ward in  such  manner  that  the  opening  in  it  will  be  outside  the  in- 
cision in  the  abdominal  walls. 

In  this  way  there  will  be  less  danger,  if  any,  of  the  contents  of  the 
tumor  escaping  into  the  peritoneal  cavity. 

This  part  of  the  operation  may  be  very  much  facilitated  by  the 
assistant  judiciously  pressing  upon  the  abdominal  walls.  When  the 
fluid  in  the  first  sac  is  thus  evacuated,  another  large  cyst,  if  any 
should  present  itself,  may  be  perforated  by  the  trocar  from  the  cavity 
of  the  main  cyst,  and  still  others  consecutively  until  the  tumor  is 
small  enough  to  pass  through  the  incision. 


766 


ABDOMINAL   OVARIOTOMY, 


Should  the  secondary  cysts  be  small  or  their  contents  so  viscid  as 
not  to  pass  through  the  trocar,  the  opening  in  the  main  sac  may  be 
enlarged  sufficiently  to  admit  the  fingers  or  hand  with  which  the 
smaller  cysts  may  be  broken  up,  and  their  contents  evacuated  through 


Fig.  300. 


Trocar. 


the  main  opening.  While  the  inside  of  the  sac  is  thus  manipulated, 
the  margins  of  the  opening  should  be  drawn  out  beyond  the  lips  of 
the  external  wound,  and  held  so  that  no  fluid  can  enter  the  abdominal 
cavity.     Sometimes  the  whole  of  the  contents  of  the  tumor  will  be  so 


Fig.  301. 


Nelaton's  Forceps. 


thick  and  tenacious  that  it  will  not  pass  through  the  trocar,  when  all 
of  them  may  be  removed  by  the  hand  in  this  way. 

When  possible  to  break  up  the  internal  cysts  with  the  fingers,  the 
hand  should  not  be  introduced.  In  doing  this  part  of  the  operation, 
great  care  should  be  taken  not  to  rupture  the  parent  cyst. 

As  the  tumor  is  collapsing  we  must  look  carefully  for  adhesions, 
and  dispose  of  them  as  we  meet  with  them.  The  omentum  may  be 
adherent  to  a  part  or  the  entire  anterior  surface  of  the  tumor. 

If  the  omental  adhesions  are  extensive  they  may  be  overcome  by 
insinuating  the  fingers  from  above  between  the  cyst  and  the  omentum 


SECOND   STEP.  767 

and  carefully  separating  them.  We  should  endeavor  to  do  this  with- 
out tearing  any  vessels  except  at  their  extremities.  After  the  separa- 
tion we  may  turn  this  membrane  back  out  of  the  wound,  and  allow 
it  to  remain  there  in  care  of  an  assistant  until  the  tumor  is  removed. 
If  it  bleeds  much,  we  may  at  once  tie  it  as  a  whole  or  in  sections, 
with  fine  silk,  and  return  it  into  the  abdomen.  If  the  adhesions  are 
small,  we  may  lift  the  adherent  portion  up  and  ligate  it  en  masse. 

I  do  not  now  think  it  necessary  to  cut  off  the  ends  of  the  omentum 
below  the  ligature,  but  return  it  all.  In  no  case  where  I  have  done  so 
has  any  disagreeable  result  followed. 

Adhesions  to  the  abdominal  wall  may  occupy  but  a  small  space  or 
they  may  be  quite  extensive,  and  may  be  in  front  or  at  lateral  portions 
of  the  parietes. 

Long  broad  fleshy  bands  sometimes  extend  from  the  abdominal 
walls  and  spread  themselves  over  the  front  and  sides  of  the  tumor. 

These  thick  fleshy  adhesions  should  always  be  ligated  before  they 
are  separated  from  the  tumor. 

If  the  flat  adhesions  of  the  surfaces  are  in  front,  we  are  often  un- 
able to  distinguish  the  peritoneum  from  other  parts,  and  as  a  conse- 
quence the  tumor  is  generally  laid  open  in  making  the  abdominal 
incision.  The  accidental  opening  is  no  disadvantage  in  such  cases,  as 
it  enables  us  to  evacuate  the  whole  of  the  contents  of  the  tumor,  with- 
out the  danger  of  having  it  flow  into  the  peritoneal  cavity. 

In  this  case  the  tumor  must  be  evacuated  before  the  adhesions  are 
broken  up.  When  the  tumor  is  thus  evacuated  we  may  overcome  the 
adhesions  by  introducing  the  hand  into  the  empty  cyst,  seizing  its 
walls  and  making  traction  from  within,  upon  the  points  of  adhesion, 
with  sufficient  force  to  cause  them  to  give  way,  and  if  there  be  no  vis- 
ceral adhesions  this  is  quite  effective  and  safe. 

Another  method  is  to  extend  the  incision  upward  until  the  boun- 
dary of  the  adhesions  is  reached  and  passed  a  short  distance,  then  we 
can  carefully  separate  them  by  the  fingers  from  above  downward  on 
the  outside  of  the  cyst.  There  is  ordinarily  some  oozing  of  blood 
from  the  abraded  surfaces,  but  the  contractions  of  the  abdominal 
walls  usually  arrest  it ;  if  not  we  may  cauterize  the  bleeding  patches 
with  the  thermal  cautery,  take  up  the  bloodvessels  separately,  and 
ligate  them,  or  pass  a  curved  needle,  armed  with  thread,  under  the 
centre  on  each  side  of  them,  and  by  drawing  the  thread,  thus  surround- 
ing the  patches,  the  surface  will  be  puckered  like  the  mouth  of  a 
purse,  compressing  the  vessels  sufficiently  to  arrest  the  hemorrhage ; 
the  thread  may  then  be  tied  and  cut  off.  In  this  way  all  danger 
from  hemorrhage  may  be  avoided.  The  long  broad  bands  of  adhe- 
sions may  be  tied  in  sections  with  fine  thread  and  cut  off  close  to 
the  tumor. 

When  it  is  necessary  to  introduce  the  hand  into  the  peritoneal  cavity, 


768  ABDOMIXAL    OVARIOTOMY. 

for  any  purpose  during  the  operation,  it  must  l3e  thoroughly  cleansed 
and  dipped  in  carbolized  water. 

As  the  tumor  is  being  drawn  slowly  from  the  abdominal  cavity,  we 
should  carefully  watch  for  visceral  adhesions.  These  should  never  be 
separated  by  traction,  as  above  described,  but  the  adherent  portion  of 
the  cyst  should  be  cut  out  with  scissors,  leaving  a  large  margin  attached 
to  the  viscera. 

To  secure  the  patient  against  the  danger  of  the  secretions,  which 
might  eventuate  from  the  surfaces  of  these  abandoned  pieces  of  cyst, 
the  inner  membrane  should  be  stripped  off  by  the  fingers  or  forceps. 
In  doing  this  we  should  retain  firm  hold  on  the  parts  by  seizing  the 
margins  of  the  adhering  patch  of  the  cyst  instead  of  the  viscera. 

These  directions  are  intended  to  apply  particularly  to  visceral  adhe- 
sions in  the  abdominal  cavity,  and  are  equally  applicable  to  those 
within  the  pelvis,  provided  the  adhesions  are  limited  and  may  be  easily 
reached  and  manipulated.  Unfortunately,  however,  sometimes  the 
tumor  adheres  with  insurmountable  firmness  to  the  whole  circle  of  the 
pelvic  cavity,  uterus,  and  bladder.  In  such  cases  I  have  no  hesitancy 
in  preferring  enucleation,  as  taught  by  Professor  Miner,  of  Buffalo. 
This  may  be  done  by  cutting  or  tearing  through  the  external  layer  of 
the  cystic  walls  above  the  point  of  adhesion, and  stripping  it  off  from 
above  downward  into  the  pelvis,  the  fingers  ma}"  be  inserted  between 
the  outer  and  inner  layers  of  the  cyst  wall,  until  the  latter,  with  the 
contents  of  the  tumor,  is  removed.  In  this  operation  the  vessels, 
arteries,  and  veins,  which  ramify  in  the  connective  tissue  adherent  to  the 
peritoneal  membrane,  are  not  torn  to  any  considerable  extent,  and  are 
separated  from  the  enucleated  tumor.  The  tumor  is  turned  out  of  its 
external  envelope,  the  broad  ligament  is  not  injured  or  disturbed ; 
the  tumor  is  removed  from  the  ovary  overlying  that  ligament.  With- 
out a  knowledge  of  its  anatomy,  seeing  the  tumor  come  out  without 
any  pedicle,  is  calculated  to  perplex  us,  and  we  can  hardly  believe  in 
the  completeness  of  the  operation. 

The  broad  ligament,  with  the  Fallopian  tube,  ovarian  ligament, 
etc.,  contained  within  it,  forms  the  pedicle,  when  the  tumor  is  lifted 
out  in  the  ordinary  operation  of  ovariotomy,  and  the  vessels  pass 
through  this  to  the  connective  tissue  immediately  beneath  the  perito- 
neum, covering  the  tumor.     These  are  all  left  behind  in  enucleation. 

The  vessels  and  peritoneal  covering  are  left  to  contract  by  their 
own  elasticity,  and  as  they  are  not  torn,  except  where  the  vessels  are 
very  small,  they  do  not  bleed  much.  If  any  vessels  bleed  after  enu- 
cleation they  may  be  ligated  separately. 

After  the  adhesions  are  overcome  and  the  contents  of  the  tumor 
removed  so  that  it  may  easily  pass  through  the  incision,  gentle  trac- 
tion will  enable  us  to  lift  it  from  the  abdominal  cavity.  One  assist- 
ant may  support  the  tumor  in  such  a  position  that  none  of  its  con- 


THIRD    STEP.  769 

tents  will  escape  into  the  pelvic  cavity  and  thus  expose  the  pedicle 
without  traction  upon  it.  After  carefully  inspecting  the  pedicle  and 
passing  the  fingers  around  and  along  the  whole  length  of  it  to  be  as- 
sured that  it  is  perfectly  isolated,  the  operator  may  pass  a  large  needle, 
armed  with  a  double  ligature  of  strong  silk  (the  braided  is  the  best), 
through  the  middle  of  the  pedicle,  an  inch  below  the  tumor,  and 
ligate  it  very  firmly  on  either  side.  The  pedicle  may  then  be  divided 
with  scissors  close  to  the  tumor.  The  division  should  be  at  least 
three-quarters  of  an  inch  from  the  ligature,  and  perhaps  an  inch  would 
be  better. 

If  divided  too  near  the  ligature  there  is  danger  that  by  retraction 
the  stump  may  be  withdrawn  from  the  loop  and  thus  permit  hemor- 
rhage to  take  place. 

We  cannot  be  too  careful  in  placing  the  ligature,  tying  it  tightly, 
and  leaving  the  stump  sufficiently  long.  If  this  part  of  the  operation 
is  not  properW  done  there  is  very  great  danger  that  the  shock  of  vomit- 
ing will  loosen  the  ligature  and  cause  the  death  of  the  patient  by  sec- 
ondary hemorrhage. 

Before  cutting  through  the  pedicle  it  must  be  surrounded  by  a 
napkin  at  the  ligated  point  to  absorb  the  blood  effused  from  the 
vessels  of  the  tumor,  and  thus  prevent  it  from  passing  into  the  peri- 
toneal cavity. 

Third  Step. 

The  third  step  in  the  operation  consists  in  cleansing  the  abdominal 
cavity  and  dressing  the  wound. 

Before  proceeding  further  the  operator  should  examine  the  contents 
of  the  pelvis;  first,  to  ascertain  whether  there  are  any  bleeding  points, 


Fig.  302. 


Sponge  Holder. 


and,  secondly,  to  assure  himself  that  the  remaining  ovary  is  sound  and 
does  not  require  to  be  removed.  If  the  other  ovary  has  commenced 
the  process  of  cystic  degeneration  it  ought  also  to  be  removed. 

If  there  have  been  adhesions,  every  point  whence  hemorrhage  is 
likely  to  occur  should  be  inspected  and  the  hemorrhage  checked  by 
the  means  above  mentioned. 

As  the  fluids — blood,  serum,  ovarian  fluids,  etc. — usually  gravitate 

49 


770  ABDOMINAL,   OVARIOTOMY. 

into   the  pelvis,  the}^  may  generally  be  cleaned  away  by  carefully 
sponging  that  cavity. 

With  the  left  hand  passed  into  the  pelvis  the  intestines  may  be 
lifted  up  and  held  out  of  the  way,  while  with  the  right  the  operator 
gently  and  repeatedly  presses  the  sponge  down  into  the  hollow  of  the 
sacrum,  and  thus  takes  up  all  the  clots,  fluid,  blood,  serum,  etc. 
When  this  process  is  finished  the  abdominal  cavity  should  again  be 
inspected  and  thoroughly  cleansed  by  the  sponges,  and  before  closing 
the  wound  the  ligatures  should  be  cut  short,  the  uterus  and  stump  of 
the  pedicle  be  placed  below  the  intestines  in  their  normal  position.  I 
think  this  last  precaution  of  properly  replacing  the  pelvic  viscera  of 
much  importance. 

I  now  close  the  incision  with  fine  silk  sutures  about  one-half  inch 
apart,  and  passed  in  half  an  inch  from  the  margin  on  the  cutaneous 
surface  so  as  to  penetrate  the  fascia,  peritoneum  and  muscle  from  the 
right,  and  penetrating  the  other  side  of  the  incision  from  within  out- 
ward at  similar  points.  When  the  incision  is  accurately  closed  I 
cover  the  wound  with  a  piece  of  patent  lint,  saturated  with  carbolized 
oil,  large  enough  to  extend  beyond  the  margins  at  least  two  inches  in 
every  direction. 

The  Avound  thus  covered  is  further  protected  by  cotton  batting  five 
or  six  inches  thick,  which  extends  over  the  whole  abdomen  and  down 
well  upon  the  symphysis. 

The  whole  is  secured  by  a  flannel  binder  from  the  pubis  to  the  ensi- 
form  cartilage  drawn  very  tightly. 

This  dressing  is  not  according  to  the  Lister  method,  but  I  think  it 
is  quite  as  effective  in  keeping  out  septic  particles. 

I  have  given  the  reader  in  detail  the  method  of  operating  which  I 
now  employ.  Like  most  other  gynecologists  who  have  practiced 
ovariotomy  since  1859,  I  have  performed  the  operation  in  many  dif- 
ferent ways,  but  for  several  years  I  have  operated  uniformly  in  the 
manner  above  described.  Every  step  in  the  operation,  as  I  now  per- 
form it,  is  done  in  the  simplest  possible  way,  and  this  I  think  a  great 
recommendation. 

I  would  impress  upon  my  readers  the  great  importance  of  gentle- 
ness of  manipulation.  We  should  not  forget,  in  the  excitement  of  the 
operation,  that  we  are  handling  the  abdominal  organs,  and  plunge  our 
hands  roughly  and  forcibly  into  the  peritoneal  cavity,  search  for  ad- 
hesions, and  tear  them  away  violently,  heedless  of  the  damage  thus 
inflicted. 

I  would  not  think  it  necessary  to  so  implicitly  insist  upon  gentle- 
ness, if  7  had  not,  on  more  than  one  occasion,  seen  the  peritoneal 
cavity,  with  its  contents,  submitted  to  such  violence. 

It  is  only  necessary  further  to  say  that  all  the  sponges  used  should 
be  new  and  thoroughly  carbolized. 


CHAPTER    XLVL 

OVARIOTOMY  (Continued). 

Accidents  that  may  occur  during  the  Operation. 

Unfortunately  in  some  cases  of  ovarian  tumors,  the  adhesions  are 
so  extensive  and  intricate,  and  the  cysts  so  changed  by  deposits  of 
albuminous  and  fibrinous  accretions,  that  the  anatomy  of  the  growth 
and  surrounding  organs  is  confused  beyond  recognition.  The  rela- 
tions of  the  viscera  and  tumor  sometimes  are  so  unusual,  and  so  con- 
trary to  all  precedent  observation,  that  the  experienced  operator  is 
sometimes  betrayed  into  mistakes  and  accidents  of  a  very  grave  char- 
acter. It  will  not  be  out  of  place,  therefore,  to  warn  the  young  prac- 
titioner of  what  may  happen,  and  what  is  the  best  way  of  managing 
accidents  that  may  occur. 

When  the  anterior  portion  of  the  cyst  is  generally  and  very  firmly 
adherent  to  the  peritoneum  of  the  abdominal  wall,  the  inexperienced 
operator  will  sometimes  find  himself  separating  the  peritoneum  from 
its  natural  attachments,  under  the  impression  that  he  is  breaking  up 
adhesions.  There  are  probably  very  few  of  us  who  have  not  com- 
mitted this  mistake  to  a  greater  or  less  extent.  This  may  generally 
be  avoided  by  making  the  incision  long  enough  to  carry  the  opening 
above  the  point  of  adhesion,  and  then  separating  it  from  above.  We 
may  recognize  the  accident  in  its  incipiency  by  turning  the  lip  of  the 
wound  strongly  outward,  and  inspecting  the  inner  surface  of  the  ab- 
dominal wall. 

The  absence  of  any  but  the  fascial  covering  of  the  muscles  will  at 
once  set  us  right.  If,  however,  the  peritoneum  should  be  separated, 
it  is  of  much  less  importance  than  we  would  expect.  In  one  instance 
I  saw  several  inches  of  that  membrane  entirely  removed  without 
affecting  the  speedy  and  perfect  recovery  of  the  patient. 

Should  this  accident  occur  unwittingly,  or  in  spite  of  our  precautions, 
the  membrane  should  still  be  separated  from  the  tumor  with  as  little 
injury  as  possible,  and  when  we  come  to  close  the  incision  the  interval 
between  the  membrane  and  the  muscles  should  be  thoroughly  cleansed, 
the  peritoneum  smoothly  applied  to  its  natural  surface,  and  included 
in  the  stitches  with  which  the  wound  is  drawn  together.  If  the 
membrane  is  so  mutilated  that  we  are  in  great  doubt  as  to  the  integrity 
of  its  structure  the  worst  part  may  be  cut  off  and  removed. 

During  incautious  separation  of  adhesions  to  the  liver,  spleen,  or 
kidneys,  these  organs  may  be  wounded.     If  the  surface  thus  injured 


772  OVARIOTOMY. 

does  not  bleed,  we  cannot  do  better,  perhaps,  than  let  them  entirely 
alone.  If,  however,  hemorrhage  results  from  the  accident  and  the 
surface  is  small,  we  may  surround  the  bleeding  space  by  a  fine  silk 
ligature,  in  the  manner  already  directed  for  similar  places  in  the  ab- 
dominal wall.  If  the  surface  is  so  large,  however,  as  to  make  this 
impracticable,  the  actual  cautery  should  be  used  for  the  purpose  of 
closing  the  vessels.  If  the  pelvic  portion  of  the  kidney  is  torn  so 
that  the  urine  flows  from  it  into  the  abdominal  cavity,  nothing  is 
left  for  us  to  do  but  to  extirpate  the  injured  organ.  I  know  of  no 
precedent  for  this  method  of  managing  such  a  case,  but  in  view  of 
the  fact  that  one  kidney  has  been  removed  for  other  conditions  with- 
out fatal  results,  I  would  not  hesitate  to  give  my  patient  the  benefit  of 
the  operation. 

Wounds  in  the  intestinal  canal,  including  the  stomach,  when  there 
is  no  loss  of  substance,  should  be  carefully  closed  with  fine  silk  sutures. 
In  closing  such  openings  the  stitches  should  be  very  near  together  to 
prevent  the  escape  of  fseces.  It  is  also  important  that  the  edges 
should  be  smoothly  coaptated,  and  the  mucous  membrane  pressed  into 
the  tube  to  make  sure  that  it  does  not  intervene  between  the  lacerated 
or  cut  edges  of  the  wound.  After  an  operation  attended  with  this 
accident  the  peristaltic  movement  of  the  bowels  should  be  quieted  by 
a  liberal  and  continued  administration  of  opiates  for  at  least  ten  days. 
The  diet  should  be  liquid,  and  probably  beef  soup,  or  beef  essence 
would  be  the  best. 

By  far  the  most  difficult  accident  (and  yet  it  would  seem  not  alto- 
gether desperate  to  manage)  is  the  wounding  of  the  urinary  bladder, 
the  gall-bladder,  or  ureter.  When  the  gall-bladder  is  wounded  the 
only  way  that  we  could  hope  to  secure  any  chance  of  escape  would  be 
to  stitch  it  into  the  wound, — and  if  necessary  the  wound  should  be 
sufficiently  elongated, — to  insure  a  temporary  discharge  of  the  bile 
externally.  Of  course  a  perfect  cleansing  of  the  abdominal  cavity  of 
all  that  fluid,  would  be  indispensable  to  the  avoidance  of  inflammation 
from  its  irritating  qualities. 

With  reference  to  the  lesion  of  the  urinary  organs  I  subjoin  an  ab- 
stract of  a  paper  read  at  a  meeting  of  the  French  Society  for  the 
Advancement  of  Science,  by  Dr.  G.  Eustache,  of  Lille  {Arch,  de  Tocol, 
April  and  May,  1880).* 

"Since  snch  wounds  are  inflicted  only  in  very  complicated  cases,  when  there  exists 
widespread,  resisting,  and  vascular  adhesions,  and  when  a  protracted  operation  is  thus 
rendered  additionally  difBciilt  by  the  more  or  less  prolonged  contact  of  urine  with  the 
peritoneum  and  lips  of  the  woimd,  they  will  indeed  become  a  serious  complication. 
This,  especially,  because  the  already  exhausted  condition  of  the  patient  warrants  perse 
a  bad  prognosis.     Such  at  least  is  the  generally  accepted  opinion.     Now,  Eustache, 


*  American  Journal  of  Obstetrics,  January,  1881. 


ACCIDENTS   THAT   MAY   OCCUR   DURING   THE   OPERATION.      773 

in  his  last  ovariotomy,  had  the  misfortune  to  make  a  large  wound  of  the  bladder,  but 
the  patient  speedily  recovered,  notwithstanding  that  the  urine  had  abundantly  flowed 
into  the  abdominal  cavity  for  over  an  hour.  This  occurrence  suggested  to  him  the 
idea  that  the  prognosis  in  similar  cases  might  be  better  than  was  generally  admitted, 
and,  provided  adequate  therapeutic  measures  were  instantly  adopted,  might  in  future 
be  still  ameliorated.  Accordingly,  the  literature  of  the  subject  was  studied,  but  the 
information  thus  gained  was  almost  nil.  The  writer,  therefore,  communicated  per- 
sonally with  many  of  the  leading  ovariotomists,  and  the  answers  he  received  tended  to 
confirm  his  previous  opinion.  He  then  proceeded  to  communicate  what  lie  had  thus 
gleaned,  and  supplements  the  whole  by  an  analysis  of  known  cases. 

"  Renal  lesions  are  in  the  first  place  considered.  The  case  of  Spencer  Wells  is  cited, 
in  which  a  firmly  adherent  kidney  was  removed  along  with  the  ovarian  tumor,  the 
patient  dying  soon  after.  Three  other  cases,  all  instances  of  erroneous  diagnosis,  are 
cited.  From  the  records  of  these  cases,  no  conclusion  can  be  drawn.  Lesions  of  the 
ureters  are  next  examined.  Three  cases  where  one  ureter  only  was  wounded  are 
given.  In  each  the  patient  was  cured  without  even  the  leaving  of  an  urinary  fistula. 
All  these  occurred  in  Germany.  The  author  was  unable  to  find  similar  instances  in 
the  records  of  the  French  and  English  surgeons." 

Finally,  vesical  lesions  are  disposed  of,  and  the  author  refers  to  an 
interesting  personal  observation  elsewhere  fully  described  (Arch,  de 
TocoL,  July,  1879).     Dr.  Eustache  concludes  as  follows : 

"  1st.  Lesions  of  the  urinary  organs  during  ovariotomy  are  very  rare. 

"  2d.  Wounds  of  the  kidney  followed  by  extirpation,  proved  fatal  in  the  only  case 
on  record. 

"3d.  Lesion  of  the  ureters  was  in  every  case  followed  by  a  cure. 

"4th.  Vesical  lesions  were  more  frequently  followed  by  a  cure  than  otherwise. 

"  5th.  When  the  ureter  is  divided  it  should  be  immediately  united  by  sutures. 
Should  this  prove  to  be  an  impossibility,  the  upper  end  of  the  ureter  should  be  secured 
in  the  walls  of  the  bladder.  If  a  uretro-abdominal  fistula  supervenes,  an  artificial  pas- 
sage, going  from  the  fistula  to  the  bladder,  should  be  established. 

"  6th.  If  the  bladder  has  been  opened  during  an  operation,  it  should  be  immediately 
sewed  up  with  carbolized  catgut,  and  a  self-retaining  catheter  introduced. 

"7th.  If  the  vesical  opening  occurs  posteriorly  (in  the  vagina),  the  catheter  and 
several  cauterizations  will  suffice  to  establish  a  cure. 

"8th.  In  all  cases  of  this  kind  subsequent  treatment  must  be  cautiously  carried  out. 

"9th.  Antiseptic  dressings  generally  assure  success." 


CHAPTER    XLVII. 

OVARIOTOMY  {Conlinued). 

After-  Treatment. 

At  the  close  of  the  operation  it  will  often  be  found  that  the  clothing 
and  person  of  the  patient  have  become  soiled,  and  it  will  be  necessary 
to  cleanse  her  and  change  the  clothing.  If  the  patient  is  strong,  and 
there  are  no  evidences  of  nervous  depression  or  shock,  this  may  be 
thoroughly  but  carefully  done,  and  the  patient  placed  in  bed.  If, 
however,  she  is  cold,  and  the  pulse  is  weak  and  quick,  and  other  signs 
of  exhaustion  show  themselves,  we  would  add  to  her  peril  by  too 
much  attention  of  this  kind.  When  we  do  not  deem  it  best  to  remove 
the  clothing  at  once,  we  should  carbolize  the  soiled  places  and  place 
dry  woollen  cloths  between  them  and  the  skin  to  protect  the  patient 
from  the  chilling  effects  of  the  dampness.  Bottles  of  warm  water 
should  be  placed  about  her  feet  and  limbs,  and,  in  marked  cases  of 
shock,  around  the  body  also. 

The  question  of  administering  stimulants  must  be  decided  by  the 
conditions  of  the  patient,  the  temperature  of  the  surface,  and  the 
character  of  the  pulse.  If  reaction  does  not  take  place  readily  under 
the  influence  of  the  warmth  and  covering,  they  should  be  resorted  to 
very  soon,  and  may  be  given  by  the  stomach  or  rectum,  or  hypoder- 
mically.  Brandy  is  generally  the  best  stimulant,  but  carbonate  of 
ammonia  or  chloroform  may  be  given  until  reaction  is  established. 
As  the  patient  recovers  from  the  influence  of  the  anaesthetic,  she  will 
generally  complain  of  pain,  and  will  require  an  anodyne,  which  should 
be  administered  without  delay  in  quantities  proportionate  to  the  pain. 
The  anodyne  may  be  repeated  at  such  intervals  and  in  such  doses  as 
are  necessary  to  keep  the  patient  free  from  pain,  and  no  more. 

The  room  should  be  darkened,  but  the  windows  so  arranged  as  to 
admit  an  abundance  of  fresh  air.  If  the  weather  is  cold,  the  tempera- 
ture ought  to  be  maintained  by  an  open  grate,  if  possible,  and  not 
above  sixty  degrees  (F.). 

Another  thing  which  I  think  should  be  insisted  upon  is,  that  the 
abdominal  muscles  be  kept  in  a  state  of  complete  rest,  by  rigid  con- 
finement to  the  dorsal  position,  until  all  danger  of  traumatic  perito- 
nitis has  passed,  that  is,  for  the  first  four  or  five  days.  In  general, 
this  position  will  not  be  very  fatiguing  if  the  influence  of  the  ano- 
dyne is  maintained  to  a  proper  degree.  The  evacuation  of  the  bladder 
by  the  use  of  the  catheter  will  be  one  of  the  means  of  promoting 
absolute  rest. 


ATTENTION    TO   THE    CLOTHING.  775 

The  more  fortunate  cases  will  require  no  other  treatment,  and  by 
good  nursing  will  pass  through  the  convalescence  without  much  in- 
convenience. 

Treatment  of  the  Wound. 

Unless  something  unusual  occurs,  such  as  discharge  from,  or  pain 
in  the  wound,  it  need  not  be  dressed  until  the  fourth  or  fifth  day. 
The  cotton  batting  and  oiled  lint  may  then  be  removed,  and  if  the 
wound  requires  no  particular  attention,  both  may  be  replaced  by  fresh 
material.  Generally  we  will  find  no  signs  of  inflammation  or  puru- 
lent discharge,  everything  looking  fresh  and  solid.  The  dressing 
should  be  removed  again  on  the  sixth  or  seventh  day,  if  suppuration 
or  some  kind  of  discharge  does  not  render  it  necessary  sooner,  and  at 
this  time  the  stitches  may  be  taken  out,  the  wound  cleansed  with  car- 
bolized  water,  and  dressed  with  adhesive  straps  so  as  to  give  sujDport 
to  the  abdominal  walls.  A  narrow  strip  of  lint,  saturated  with  car- 
bolized  oil,  should  then  be  placed  over  the  straps  and  the  wound, 
where  they  cross  it.  From  this  time  forward  the  dressing  should  be 
examined  and  attended  to  every  second  day,  and,  if  need  be,  every 
day  until  consolidation  is  complete,  which,  when  everything  goes  on 
well,  will  be  in  from  fourteen  to  twenty  days.  During  all  of  this 
time,  and  for  two  or  three  weeks  longer,  the  binder  and  cotton  should 
be  continued,  the  latter  gradually  made  thinner  at  each  dressing  until 
it  can  be  omitted. 

Attention  to  the  Clothing. 

When  it  is  possible  to  put  the  patient  to  bed  with  her  clothes  clean 
and  dry,  every  care  should  be  taken  to  keep  them  so,  and  no  change 
made  until  the  fourth  day.  After  that  time,  changes  can  be  made 
as  often  as  necessary  to  preserve  cleanliness.  It  is  often  difficult, 
when  a  patient  is  very  weak,  to  determine  how  much  we  may  do  to- 
ward removing  soiled  clothing.  Remembering  that  the  exertion  is 
a  cause  of  further  prostration,  and  that  soiled  clothing  is  a  source  of 
sepsis,  the  practitioner  will  be  compelled  to  decide  how  much  the 
patient  can  bear,  and  personally  supervise  all  attempts  at  changing 
the  clothing  and  bed.  If  it  is  deemed  improper  to  remove  the  gar- 
ments which  have  become  soiled,  we  can  do  much  to  avert  the  dele- 
terious effects,  which  might  otherwise  occur,  by  using  carbolic  acid 
freely  upon  the  soiled  portions,  and  placing  dry  woollen  cloths  next 
the  patient. 

There  are  two  symptoms  so  frequently  met  with  after  ovariotomy, 
apart  from  any  dangerous  pathological  conditions,  that  they  ought  to 
be  considered  before  studying  the  graver  difficulties.  While  they  are 
often  not  the  result  of,  nor  accompanied  by,  septic  fever,  nor  other  of 
the  more  fatal  consequences  of  ovariotomy,  yet,  if  not  arrested  or 


776  OVARIOTOMY. 

properly  managed,  they  may,  and  sometimes  do,  lead  to  a  fatal  ter- 
mination.    I  allude  to  vomiting  and  tympanites. 

Vomiting. 

In  many  instances  troublesome  nausea  and  vomiting  occur  imme- 
diately after  the  operation.  When  this  is  the  case  it  is  generally  the 
effect  of  the  anaesthetic  upon  the  nerve  centres,  and  it  is  attended  with 
vertigo,  and  more  or  less  headache.  Cold  applications  to  the  head 
and  a  hot  water  bag  to  the  back  of  the  neck,  together  with  hot  brandy 
and  water,  in  small  quantities  internally,  will  generally  relieve  it. 

A  hypodermic  injection  of  morphia  and  atropia,  given  at  the  time 
or  soon  after  the  operation  is  finished,  will  often  relieve  both  the 
pain  and  vomiting.  Sometimes  this  symptom,  arising  from  this 
cause,  will  continue  for  two  or  three  days,  and  gradually  subside ; 
and,  when  it  resists  appropriate  remedies  for  twenty-four  hours,  it 
would  be  as  well  to  not  medicate  the  patient  much. 

When  vomiting  is  caused  by  the  secondary  effects  of  opium,  or  some 
of  its  preparations,  it  is  apt  to  come  on  the  second  or  third  day.  The 
opium  completely  arrests  digestion,  and  the  ingesta  undergoes  chem- 
ical decomposition,  and  the  materials  thrown  up  are  very  sour,  and 
have  a  grass-green  appearance.  The  patient  is  pale,  cool,  and  quiet, 
though  not  stupid.  The  pulse  is  not  changed,  except,  perhaps,  weak- 
ened. The  urine  scanty,  and  ordinarily  there  is  an  abundant  precipi- 
tate. This  is  usually  a  troublesome  form  of  vomiting,  and  is  benefited 
most  by  stimulants,  as  champagne  and  very  strong  coffee  in  small 
quantities.  Carbonate  of  ammonia  is  often  very  useful.  While  the 
patient  is  fully  under  the  influence  of  the  opiate,  the  vomiting  is 
moderated,  if  not  entirely  controlled;  and  it  is  sometimes  a  question 
whether  we  continue  or  withdraw  the  opium.  When  pain,  septic 
fever,  or  other  such  indications  exist,  I  would  not  hesitate  to  keep  the 
patient  under  the  influence  of  opium  sufficiently  to  relieve  the  pain 
and  vomiting  together  by  hypodermic  administration,  or  the  use  of 
suppositories  containing  morphia. 

The  forms  of  vomiting  here  mentioned  are  sometimes  so  obstinate 
as  to  make  it  impossible  to  administer  medicine  or  nourishment  b}'' 
the  stomach ;  and  we  often  protract  the  suffering  of  our  patient  by 
vain  attempts  to  do  so.  Generally  it  will  be  better  practice  to  ad- 
minister all  of  these  by  the  rectum  and  by  hypodermic  injections,  and 
allow  the  stomach  complete  rest. 

Rectal  administrations  are  so  efficacious,  when  well  managed,  that 
a  patient  may  be  sustained  by  them  for  many  days. 

Dr.  Henry  J.  Campbell,*  of  Augusta,  Georgia,  by  some  interesting 

*  In  Gynecological  Transactions. 


TYMPANITES.  777 

experiments,  has  enabled  us  to  understand  why  food  may  be  com- 
pletely digested  when  administered  per  rectum. 

He  found  that  the  milk  he  injected  into  the  rectum  of  a  calf  made 
its  way  up  into  the  small  intestines,  where  it  could  be  mixed  with  the 
digestive  fluids.  Milk,  eggs,  beef  essence,  finely  chopped  beef,  and 
perhaps  other  forms  of  animal  food  in  small  quantities,  may  be  re- 
tained and  digested  in  sufficient  amounts  to  sustain  the  patient  until 
the  stomach  will  regain  its  power  of  retention. 

Tympanites. 

Until  the  antiseptic  method  of  conducting  surgical  operations  was 
applied  to  ovariotomy,  t^^mpanites  was  of  very  much  more  common 
occurrence  than  now.     Dr.  Peaslee*  says  : 

"  Some  degree  of  tympanites  usually  occurs,  even  in  the  simplest  cases,  on  the  second 
or  third  day  after  ovariotomy,  on  account  of  the  diminished  contractility  of  the  ali- 
mentary canal,  and  in  such  cases  it  subsides  in  the  course  of  four  or  five  days  under 
the  simplest  treatment." 

The  conditions  which  usually  give  rise  to  the  more  obstinate  forms, 
when  not  a  complication  of  general  traumatic  or  septic  peritonitis, 
according  to  Dr.  Peaslee,  is  atony  of  the  intestinal  canal,  spasmodic 
condition  of  the  sphincter  ani,  obstruction  of  the  canal  by  fecal  accu- 
mulations, twisting  of  a  convolution  of  the  small  intestine,  and  me- 
chanical obstruction  external  to  the  alimentary  canal  itself. 

Tympanites  from  the  first  of  these  causes  occurs  as  often  as  before 
the  use  of  antiseptics. 

Where  we  have  to  deal  with  the  second  condition  a  rectal  tube  in- 
troduced and  kept  in  the  rectum  will,  sometimes,  be  sufficient  to  re- 
lieve it. 

The  third  cause  of  tympanites  is  more  difficult  to  diagnose  and  also 
to  manage.  If  the  alimentary  canal  is  well  evacuated  before  the  op- 
eration this  form  will  not  often  occur.  When  we  believe  this  to  be 
the  cause  it  will  be  operative  only  when  in  connection  with  atony  of 
the  muscles  of  the  alimentary  canal,  and  may  be  best  relieved  by 
stimulating  enemata  through  a  long  tube,  faradization,  as  practiced 
by  Dr.  Anthony  on  one  of  Mr.  Well's  patients,  by  a  tight  binder,  a 
roller  around  the  abdomen,  and,  if  the  stomach  is  not  irritable,  by  the 
administration  of  piperine,  extract  of  nux  vomica,  and  belladonna. 
For  the  fourth  variety,  or  twisting  of  the  alimentary  tube,  and  the 
fifth,  obstructions  from  mechanical  causes  outside  the  alimentary 
canal,  our  resources  are  very  limited,  and  the  means  of  relief  haz- 
ardous. 

*  Ovarian  Tumors. 


778  OVARIOTOMY. 

These  means  are  the  knee-chest  position  and  injections  of  large 
quantities  of  hot  water,  puncture  of  the  intestinal  tube  with  the 
smallest  aspirating  needle  and  opening  the  wound,  thus  correcting 
the  twisted  condition  or  dislodging  the  canal  from  any  confinement 
in  which  it  may  be  placed. 

In  continuation  of  the  subject  of  after-treatment  of  ovariotomy 
we  must  consider  the  more  grave  accidents  and  conditions  to  be  met 
with. 

How  do  these  patients  usually  die  ?  1st,  by  shock  and  collapse ; 
2d,  hemorrhage;  3d,  acute  (traumatic)  peritonitis;  4th,  septicaemia, 
complicated  or  not,  with  tympanites. 

Shock  or  nervous  depression  is  almost  always  manifested  at  the 
close  of  the  operation,  and  is  marked  by  paleness  of  the  surface, 
feebleness,  and  general!}^  quickness  of  the  pulse,  with  great  languor, 
and  sometimes  entire  inability  to  move.  The  nervous  depression 
passes.into  exhaustion,  and  death,  in  some  instances,  follows  within  a 
few  hours ;  while  in  other  cases  the  patient  may  linger  in  a  state  of 
depression  for  three  or  four  days,  and  then  die  from  no  apparent 
cause  except  the  continuation  of  the  shock. 

In  the  most  profound  cases  of  shock  we  should  apply  dry  heat  ex- 
ternally to  as  great  a  degree  as  the  jDatient  can  bear,  and  keep  her 
as  still  as  possible,  remembering  that  every  movement  adds  to  the  ex- 
haustion. The  heat  may  be  ai3j)lied  by  a  large  number  of  hot  bricks, 
stones,  and  irons. 

They  should  be  applied  the  whole  length  of  the  patient,  to  the  feet, 
legs,  trunk,  arms,  shoulders,  and  head,  and  at  the  same  time  the  tem- 
perature of  the  room  should  be  raised.  Applications  of  heat  to  the 
head  is  of  more  importance  probably  than  anywhere  else,  for  stimu- 
lating the  brain  will  often  arouse  the  whole  nervous  system  and  dispel 
the  symptoms. 

The  most  effective  way  to  do  this  is  by  using  the  rubber  coil  and 
passing  hot  water  through  it  instead  of  cold.  Plenty  of  warm  covering 
will  be  necessary,  of  course,  and  if  the  stomach  is  not  irritable  the 
patient  should  drink  as  much  hot  water  as  she  can.  I  am  quite  sure 
that  the  vigorous  application  of  heat  in  this  way  is  much  more  effec- 
tive than  alcoholic  or  other  medical  stimulants.  These,  however,  may 
be  added  and  administered  by  the  stomach,  rectum,  or  hypodermically. 
If  the  depression  succeeding  the  shock  should  last  and  be  threatening 
in  degree  the  heat  should  be  continued;  nourishment  and  internal 
stimulants  administered  perseveringly  until  reaction  is  established. 

Hemorrhage 

Is  said  to  proceed  from  the  following  different  sources :  1st.  From 
the  pedicle  in  consequence  of  the  imjaerfect  application  of  the  ligature, 


TRAUMATIC   PERITONITIS.  779 

or  the  retraction  of  the  tissues  included  in  its  grasp,  so  that  it  hecomes 
loosened.  2d.  From  wounded  surfaces  left  by  the  separation  of  ad- 
hesions. This  last  is  not  often  fatal  as  a  hemorrhage,  but  it  may- 
become  so  in  rare  instances.  The  blood  derived  from  this  source  is 
however  apt  to  decompose  and  cause  septicaemia.  3d.  From  rupture 
of  a  plexus  of  veins  near  the  ligature  or  elsewhere  in  the  pelvis.  Dr. 
Peaslee  lost  a  patient  from  hemorrhage,  and  on  a  post-mortem  exami- 
nation found  that  it  proceeded  from  this  source.  He  also  speaks  of 
others.  4th.  In  certain  conditions  of  the  blood  predisposing  to  hem- 
orrhage, the  blood  from  the  inner  portion  of  the  incision  finds  its  way 
into  the  abdominal  cavity  in  considerable  quantities, 

I  met  with  an  instance  where  hemorrhage  from  the  wound  im- 
mediately under  the  skin,  the  blood  escaping  outside,  gave  me  a  great 
deal  of  trouble.  In  this  case  the  blood  was  so  changed  that  coagu- 
lation did  not  occur  after  standing  ten  hours,  and  astringents  locally 
applied  failed  to  stop  the  hemorrhage,  and  the  only  way  it  was  arrested 
was  by  putting  pins  through  the  lips  of  the  wound  half  an  inch  apart 
and  plugging  the  wound  tightly  in  the  interspaces,  5th.  From  an 
artery  perforated  by  a  needle  used  in  closing  the  wound  (Wells).  6th. 
From  the  patulous  extremity  of  the  Fallopian  tube. 

In  all  of  these  conditions  hemorrhage  may  follow  the  operation  im- 
mediately or  occur  any  time  during  the  convalescence.  Succussion 
from  coughing,  straining  to  vomit,  moving  about  too  much,  mental 
excitement,  may  all  contribute  to  start  up  hemorrhage  when  the  pre- 
disposing conditions  exist.  When  the  hemorrhage  takes  place  from 
the  pedicle  or  ruptured  veins,  the  symptoms  generally  appear  sud- 
denly and  are  marked  in  character.  They  need  not  be  enumerated 
here  ;  but  where  the  hemorrhage  goes  on  slowly  from  abraded  surfaces 
the  symptoms  are  sometimes  very  obscure.  Increasing  rapidity  and 
weakness  of  the  pulse,  paleness  of  the  face,  coldness  of  the  extremities, 
profuse  perspiration,  nausea,  and  vomiting  coming  on  any  time  after 
the  first  twelve  hours,  when  not  pre.ceded  by  evidence  of  shock,  are 
symptoms  which  point  strongly  to  this  accident. 

When  the  symptoms  of  hemorrhage  become  marked,  there  is  but 
one  sure  way  of  giving  the  patient  a  chance  for  her  life,  and  that  is, 
to  open  the  wound,  explore  for  the  source  of  the  hemorrhage,  and 
ligate  the  vessels  or  bleeding  points  when  found.  The  abdomen 
should  be  very  carefully  cleansed  of  the  blood. 

Traumatic  Peritonitis. 

Peritonitis,  caused  by  opening  the  abdomen,  judging  from  my  own 
observations,  as  well  as  the  reports  of  others,  is  not  very  common,  and 
has  become  less  so  since  the  antiseptic  methods  have  come  into  gen- 
eral use.  At  a  time  when  our  experience  was  small,  compared  with 
what  it  now  is,  this  was  the  most  feared  of  all  the  consequences  of  the 


780  OVARIOTOMY. 

operation.  This  fear  was  founded  upon  the  well-known  fact  of  the 
fatality  resulting  from  accidental  peritoneal  wounds. 

Fortunately  we  now  know  that  the  susceptibility  of  the  peritoneum 
has  been  very  much  overrated,  and  also  that  in  cases  requiring  ovari- 
otomy, it  has  lost  much  of  the  tendency  to  inflammation  which  it 
possesses  in  a  healthy  condition.  The  long-continued  distension, 
friction,  and  frequent  inflammations,  to  which  it  has  been  subjected, 
so  modify  its  structure  as  to  greatly  alter  its  appearances,  and  in  almost 
all  instances  to  reduce  its  tendency  to  inflammatory  processes  very 
much.  Hence  we  expect  oftentimes  to  escape  this  very  dangerous 
affection.  When  it  does  come,  it  makes  its  appearance  within  the 
forty-eight  hours  immediatel}''  succeeding  the  operation.  Its  symp- 
toms are  pain,  tenderness,  and  tumefaction  of  the  lower  part  of  the 
abdomen,  frequent  pulse,  and  elevation  of  the  temperature.  In  unfa- 
vorable cases  these  symptoms  rapidly  increase  until  the  abdomen  is 
largely  distended  and  very  tender ;  the  pulse  rises  to  130  to  150,  or 
even  160;  the  heat  increases  as  high  as  106  degrees.  Mental  dis- 
turbances become  a  prominent  feature  toward  the  close.  These  cases 
often  run  their  course  to  a  fatal  termination  in  two  or  three  days  from 
the  beginning.  The  temperature  and  the  pulse  are  the  best  guides  to 
the  intensity  of  the  inflammation.  When  the  former  does  not  rise 
above  103  degrees,  and  the  latter  above  120  per  minute,  we  may  have 
a  reasonable  hope  of  recovery. 

The  objects  in  the  treatn:ient  of  this  form  of  peritonitis  are  to  curb 
vascular  excitement,  reduce  the  temperature,  and  control  pain.  Opium 
in  large  doses,  commenced  at  once  and  continued  to  deep  narcotism, 
will  go  a  great  way  toward  accomplishing  all  of  these  objects,  I  be- 
lieve that  this  treatment,  at  the  very  inception,  will  sometimes  at  once 
break  the  force  of  the  attack.  After  the  first  forty-eight  hours,  or  even 
sooner,  large  doses  of  quinine  may  be  added  to  the  opiate  treatment, 
when  the  opium  should  be  slowly  withdrawn  and  brandy  substituted 
for  it.     The  quinine,  however,  should  be  continued. 

These  remedies,  quinine  and  brandy,  arrest  the  waste  which  follows 
the  first  stage.  With  these,  nourishment  should  be  pushed  to  the 
capacity  of  the  stomach  and  rectum.  When  there  is  vomiting,  these 
remedies  may  be  given  hypodermically  and  per  Tectum.  Ice  and 
ice-cold  water  may  be  allowed  as  desired,  according  to  the  craving  of 
the  patient.  Thornton's  cap  will  be  of  great  service  in  these  cases 
also,  as  the  cold  water  circulating  through  it  will  greatly  reduce  the 
general  temperature.  A  question  of  great  importance  is,  AVhat  ap- 
plications shall  be  made  to  the  abdomen  ?  In  the  first  two  days,  if 
the  temperature  is  high,  I  should  have  no  hesitancy  in  applying  cold 
by  means  of  the  water-bag ;  but  I  should  promptly  change  from  this 
to  warm  applications  after  the  stage  of  eflusion  had  passed,  about 
the  third  day  of  the  disease. 


SEPTICEMIA.  781 


Septicsemia. 


This  is  another  of  the  formidable  and  fatal  sequences  of  ovariotomy. 
As  the  operation  is  now  performed, — that  is,  with  antiseptic  precau- 
tions,— it  ma}''  generally  be  avoided. 

The  most  common  cause  of  septicaemia  is  the  retention,  decompo- 
sition, and  absorption  of  fluids  from  the  tumor,  or  from  extravasated 
blood.  The  observations  of  numerous  operators  have  established  the 
fact  that  the  retention  of  these  fluids  does  not  always  result  in  septic 
fever,  because  they  do  not  always  undergo  decomposition;  especially 
is  this  the  case,  as  before  intimated,  if  the  antiseptic  precautions  have 
been  faithfully  and  sufficient!}^  carried  out.  When  it  does  occur,  it 
may  follow  the  reaction  which  succeeds  the  protracted  depression  of 
shock;  but  when  not  occurring  in  this  way,  it  comes  on  in  from- four 
to  seven,  and  even  ten,  days  after  the  operation.  Its  course  is  vari- 
able, terminating  sometimes  in  five  or  six  days,  especially  when  com- 
plicated, and  this,  I  think,  rather  a  frequent  thing  with  peritonitis  ; 
while  in  the  simple  form  it  may  last  for  ten  or  twenty  days,  or  even 
longer,  before  wearing  the  patient  out  or  merging  into  convalescence. 

The  prognosis,  although  bad,  is  not  absolutely  desperate.  Some- 
times the  attack  is  sudden,  inaugurated  by  a  chill,  and  succeeded  by 
a  rise  of  temperature  and  accelerated  pulse;  or  it  may  be  established 
in  a  very  gradual  manner,  the  pulse  and  temperature  rising  slowly. 
They  are  generally  both  much  higher  in  the  after-part  of  the  day. 
Derangement  of  particular  organs  is  not  uniform.  The  skin,  some- 
times dry  and  hot,  is  often  bathed  in  a  copious  perspiration,  the  per- 
spired fluid  being  sometimes  very  thin  and  watery,  and  again  quite 
viscid  and  sticky.  The  stomach  may  or  may  not  be  disturbed,  but 
generally  the  rest  of  the  alimentary  canal  is  more  or  less  irritated,  and 
diarrhoea,  with  profuse,  thin,  stinking  stools,  is  often  a  marked  feature 
of  septicaemia.  Nervous  excitement  and  delirium,  or  somnolence  and 
apathy,  form  part  of  the  symptoms  in  different  cases.  In  many 
instances  great  tympanites,  with  or  without  peritonitis,  add  to  this 
mischief.  In  the  course  of  the  disease,  the  circulating  fluid  some- 
times becomes  decomposed  to  such  an  extent  as  to  pass  easily  out  of 
the  capillaries,  giving  rise  to  maculas,  blebs,  and  bullse,  or  appearing 
in  the  urine  or  dejecta  from  the  bowels,  or  exuding  from  the  exposed 
mucous  membrane  in  the  mouth  or  nostrils.  More  frequently,  how- 
ever, the  disease  runs  its  course  rapidly  when  a  very  quick  pulse, 
from  120  upward,  high  temperature,  from  104  degrees  upward,  de- 
lirium, excitement,  or  somnolence,  and  apathy  constitute  the  impor- 
tant and  noticeable  symptoms.  In  either  the  slow  or  rapid  case  the 
stomach  will  not  digest  the  food  taken,  and  the  lacteals  will  not 
absorb  the  material  exposed  to  their  action.  Sanguification  is  ar- 
rested, and  the  scorching  temperature  is  maintained  by  combustion 


782  OVARIOTOMY. 

of  the  material  in  the  blood,  which  ought  to  sustain  the  vital  func- 
tions. The  patient  is  soon  exhausted  under  this  rapid  waste,  being 
incajiable  of  a^Dpropriating  anything  with  which  to  supply  the  de- 
ficiency. 

Treatment. 

The  most  important  item  in  the  treatment  of  septica3mia  arising 
after  ovariotomy  is  to  remove  the  cause.  This,  as  has  already  been 
said,  is  decomposing  substances  in  the  peritoneal  cavity.  In  almost 
all  cases  the  decomposing  substances,  serum,  blood,  etc.,  gravitate  to 
the  bottom  of  the  cul-de-sac  of  Douglas,  where  we  can  reach  it.  The 
fluid  can  usually  be  detected  per  vaginam,  but  sometimes  the  quan- 
tity is  so  small  as  not  to  be  appreciable  by  such  an  examination.  In 
either  case  we  should  open  the  peritoneal  cavity  through  the  vagina, 
introduce  a  drainage-tube,  and  wash  out  the  pelvic  cavity  with  warm 
water.  We  may  open  the  peritoneal  cavity  by  means  of  scissors. 
The  patient  may  be  turned  upon  her  side,  Sims's  speculum  intro- 
duced, and  the  j^osterior  wall  of  the  vagina  lifted  up  by  a  hook  and 
perforated.  The  opening  in  the  vagina  should  be  in  the  median  line 
as  nearly  as  possible.  The  incision  should  be  large  enough  to  admit 
a  good-sized  tube.  Through  this  the  fluid  will  escape,  and  we  may 
throw  water  into  the  pelvis.  We  may  also  perforate  the  posterior 
vaginal  wall  with  a  trocar.  This  may  be  done  very  easily  when  the 
quantity  of  fluid  is  considerable  and  the  retrouterine  pouch  well  dis- 
tended. If  opened  in  this  way  the  first  washing  maybe  done  through 
the  canula  before  it  is  withdrawn,  after  which  a  tube  should  be  passed 
through  the  canula,  and  as  the  latter  is  withdrawn  the  former  is  re- 
tained, or  we  may  remove  the  two  lower  stitches  and  introduce  the 
drainage-tube  through  the  lower  end  of  the  wound. 

The  cleansing  of  the  abdominal  cavity  will  require  repetition  in 
proportion  to  the  amount  of  decomposing  materials.  Of  course  no 
one  would  think  of  performing  this  operation  until  septic  fever  is 
evident.  When  this  is  the  case  the  risk  of  evacuating  the  fluid  and 
cleansing  the  pelvic  cavity  ought  certainly  to  be  considered  a  neces- 
sity, and  when  indicated  it  is  worth  more  than  all  the  remedies  we 
can  bring  to  bear  in  the  treatment.  The  rest  of  the  treatment  has  for 
its  object  the  relief  of  symptoms,  preventing  waste,  and  introducing 
as  much  nourishment  as  can  be  borne  by  the  stomach,  rectum,  or 
both,  and  hypodermically. 

Probably  the  most  important  symptom  to  be  attended  to  is  the 
high  temperature.  This  may  be  combated  by  cold  externally  ap- 
plied or  administered  internally.  Cold  can  be  very  eff'ectually  ap- 
plied to  the  head  by  means  of  the  ice-cap  invented  by  Mr.  Thornton, 
of  the  Samaritan  Hospital.  It  is  very  highly  recommended  by  Mr. 
Wells.     It  is  a  coil  of  rubber  tubing  so  arranged  as  to  fit  the  head  like 


REMARKS. 


783 


a  cap,  and  when  aj^plied  to  the  head  the  tube  is  filled  with  ice- water, 
and  one  end  is  placed  in  a  bucket  of  ice-water  very  slightly  elevated 
above  the  head  of  the  patient,  while  the  other  end  is  passed  into  a 
tub  under  the  bed  or  elsewhere. 

By  elevating  and  depressing  the  two  ends  of  the  tube  the  water 
may  be  made  to  run  more  or  less  swiftly  through  the  portion  forming 
the  cap  as  we  may  desire.  If  this  cap  cannot  be  commanded,  india- 
rubber  bags  or  coils  filled  with  ice-water,  or  a  large  beef's  bladder,  or 
ice  inclosed  in  rubber  cloth  or  oiled  silk  may  be  substituted. 

Cold  may  thus  be  applied  with  sufficient  intensity  to  lessen  the 
heat  of  the  entire  body  in   a  very  short  time,  and  I  think  is  very 


Fig.  303. 


Fig.  304. 


Rubber  Coil. 

much  to  be  preferred  to  any  general  application  of  cold  however 
made. 

Quinine  and  antipyrin  administered  in  large  quantities  are  very 
efficient  in  reducing  temperature  and  preventing  waste;  so  also  is 
alcohol.  Five  grains  of  quinine  every  four  hours,  or  ten  grains  every 
eight  hours,  or  a  like  amount  of  antipyrin,  is  the  proper  dose.  Brandy 
in  ounce  doses  every  two  hours  may  be  given  for  a  like  purpose.  If 
tympanites  or  peritonitis,  or  both,  complicate  the  fever,  there  are  local 
means  for  their  treatment,  as  elsewhere  detailed. 


Remarks. 

I  am  among  those  who  believe  in  antiseptic  surgery.  My  opera- 
tions date  back  to  1861,  when  everything  in  connection  with  ovari- 
otomy was  in  an  unsettled  state.  It  is  true  that  there  is  not  perfect 
accord  among  ovariotomists  at  the  present  time,  but  we  have  had  a 
great  deal  of  experience  in  diff'erent  methods  of  procedure,  in  the 
several  steps  of  the  operation  and  after-treatment,  and  can  conse- 
quently more  intelligentl}^  estimate  them ;  and  I  think  it  safe  to  say 


784  OVARIOTOMY. 

that  the  antiseptic  process  has  about  done  away  with  the  clamp  and 
primary  drainage. 

My  convictions  as  to  the  benefit  of  the  antiseptic  processes  in  ovari- 
otomy are  grounded  upon  my  own  experience  more  than  general 
statistics,  although  I  think  the  latter  are  sufficiently  convincing. 

While  there  has  been  a  very  marked  change  for  the  better  since 
adopting  the  antiseptic  method,  I  think  my  mind  has  been  influenced 
in  coming  to  a  conclusion  favoring  antiseptic  practice  by  the  appear- 
ance of  the  wound.  So  far  as  the  wound  is  concerned  there  is  no  ques- 
tion about  the  effects  of  the  dressing.  When  properly  managed  there 
is  no  smell,  no  pus,  and  no  ulceration.  It  heals  without  any  evidence 
of  decreased  vitality  in  the  part.  In  expressing  my  belief  in  the 
efficacy  of  antiseptic  processes  in  surgery  I  do  not  announce  any 
opinion  of  the  modus  operandi.  I  am  not  sure  that  there  are  septic 
particles  that  fall  upon  and  induce  ferment  in  the  wounded  parts,  or 
living  germs  or  ova  that  infest,  breed,  and  diffuse  themselves  in  such 
numbers  as  to  destroy  the  vitality  of  the  points  of  attack,  and  gaining 
access  to  the  vessels  disintegrate  the  circulating  fluid  so  that  it  is  not 
fit  to  support  the  vital  forces,  and  that  the  carbolic  acid  operates  by 
consuming  these  deleterious  particles.  But  I  do  believe  that  it  adds 
greatly  to  our  means  of  avoiding  one  if  not  more  of  the  untoward 
conditions  sometimes  experienced  after  ovariotomy. 

Tumor  of  the  Broad  Ligament,  or  Parovarian  Tumor. 

This  tumor  has  its  origin  in  the  minute  serous  canals  situated  in 
the  broad  ligament  between  the  outer  extremity  of  the  Fallopian  tube 
and  the  ovary.  Although  small  they  are  easily  seen  by  holding  the 
part  between  th€  eye  and  a  bright  light.  The  fluid  occupying  these 
tubes  is  simple  serum.  The  tumor  seems  to  consist  of  the  great  hy- 
pertrophy and  distension  of  these  canals  from  hypersecretion  of  the 
natural  fluid  contained  in  them.  The  tumor  thus  occasioned  some- 
times grows  very  large.  While  usually  not  so  great  in  size,  occa- 
sionally they  grow  sufficiently  to  cause  distressing  distension  of  the 
abdomen.  They  always  assume  the  form  of  a  single  cyst.  The 
anatomy  of  this  cyst  is  very  simple.  It  is  lined  by  a  delicate  serous 
membrane  and  covered  by  the  peritoneum.  These  two  membranes 
are  held  together  by  connective  tissue  and  form  a  frail  connection 
between  them.  These  are  the  essential  anatomical  elements  of  the 
tumor.  But  often,  as  they  grow  large  the  fibrous  tissue  of  the  broad 
ligament  is  carried  up  with  the  increasing  tumor,  covering  the  cyst  up- 
ward for  some  distance.  The  fibres  of  this  covering  are  sometimes  so 
abundantly  increased  as  to  form  large  fleshy  bands  stretching  in  every 
direction  around  the  base  of  the  tumor.  Sometimes  this  envelope  is 
hardly  noticeable  except  at  the  very  bottom  of  the  growth. 


PAEOVAEIAX    TUMOR — SYMPTOMS.  785 

The  parovarian  tumor  is  meagrely  supplied  with  blood,  hence  their 
usual  slow  growth.  The  bloodvessels  are  found  in  the  fibrous  cover- 
ing and  consist  of  many  small  arteries  and  veins,  running  up  from 
the  broad  ligament.  No  large  arterial  trunk,  such  as  is  found  passing 
through  the  pedicle  of  an  ovarian  tumor,  belongs  to  the  system  of 
vessels  supplying  this  growth. 

This  arrangement  makes  it  easy  to  enucleate  the  tumor  by  care- 
fully stripping  off  the  fibrous  covering  containing  the  vessels.  When 
properly  done  this  operation  is  seldom  followed  by  any  considerable 
loss  of  blood. 

Occasionally,  instead  of  the  broad  ligament  tissues  growing  up  with 
and  on  the  tumor,  this  latter  seems  to  spring  from  the  surface  of  the 
ligament ;  thus  presenting  sufficient  pedicle  to  ligate  safely. 

The  microscopy  and  chemistry  of  the  fluid  contents  of  the  parova- 
rian tumor  are  not  very  marked.  They  prove  it  to  be  very  pure 
serum.  Under  the  influence  of  inflammation  or  violence  the  serum 
may  be  very  much  modified  by  the  addition  of  the  products  of  those 
conditions,  hence  come  pus  corpuscles,  a  more  or  less  abundant  sup- 
ply of  albumen  and  blood  globules. 

Etiology. 

The  time  of  life  in  which  this  tumor  shows  itself  is  the  same  as 
that  usually  occupied  by  ovarian  cystomata,  viz.,  from  puberty  to  the 
, menopause.  It  is  comparatively  rare.  From  my  own  observation,  I 
should  say  it  occurred  in  about  six  per  cent,  of  the  cysts  springing 
from  the  ovarian  region.  The  cause  of  the  parovarian  tumor  is  not 
obvious  ;  but  consists  of  some  influence  that  increases  the  secretion  of 
the  natural  fluid  of  the  parovarium,  or  prevents  the  absorption  of  it. 

Synvptoms. 

There  are  no  subjective  symptoms  announcing  this  growth  until  it 
is  large  enough  to  cause  inconvenient  pressure.  As  the  growth  is  very 
slow,  inconvenience  from  pressure  occurs  late.  Sometimes  after  attain- 
ing considerable  bulk  their  thin  wall  gives  way  and  the  fluid  is  evacu- 
ated from  the  cyst  and  emptied  into  the  peritoneal  cavity.  As  a 
consequence  of  this  accident  in  some  instances  the  tumor  disappears, 
the  fluid  is  absorbed  and  the  patient  is  well.  More  frequently,  how- 
ever, the  fluid  reaccumulates. 

The  rupture  of  the  cyst  and  the  discharge  of  its  contents  into  the 
peritoneal  cavity  gives  rise  to  sharp  pain  and  slight  shock  succeeded 
by  moderate  febrile  reaction  and  collapse  of  the  abdominal  tumefac- 
tion. The  symptoms  generally  disappear  in  a  few  days  and  the 
patient  considers  herself  well,  to  be  disappointed  by  the  reappearance 
of  the  tumor. 

60 


786  OVARIOTOMY. 

Diagnosis. 

To  make  a  clear  differential  diagnosis  between  broad  ligament  and 
ovarian  tumors,  is  not  always  possible  without  tapping  or  exploratory- 
incision.  But  the  following  are  some  of  the  more  obvious  points 
of  difference  between  them.  The  ovarian  tumor  is  seldom  mono- 
cystic,  that  of  the  broad  ligament  is  generally  so.  The  ovarian  tumor 
is  filled  to  great  tenseness,  and  the  cyst  wall  is  thick  and  strong,  mak- 
ing distinct  resistance  to  pressure ;  the  parovarian  tumor  is  not  usuall}^ 
so  tense  and  resistent  to  pressure.  The  wall  is  so  thin  and  often  so 
flaccid  as  to  permit  of  visibly  undulating  fluctuation.  It  is  generally 
quite  globular  and  symmetrical  in  shape,  while  the  ovarian  tumor 
usually  presents  some  unevenness  of  surface  and  the  fluctuation  is  not 
the  same  in  every  direction,  some  places  having  more  than  others. 
The  fluctuation  in  the  parovarian  tumor  is  the  same  from  all  points, 
and  in  the  greater  the  same  as  the  smaller  distances.  In  small  sized 
parovarian  cysts  they  are  sometimes  more  laterally  located  than  the 
ovarian  tumor.  Per  vaginam  the  base  feels  more  fleshy  and  occa- 
sionally both  ovaries  may  be  felt.  The  ovaries  are,  however,  not 
usually  within  reach. 

Prognosis. 

As  the  tumor  grows  slowly  it  requires  a  much  longer  time  to  cause 
graver  symptoms  than  the  ovarian.  Indeed,  it  generally  takes  a  very 
long  time  for  it  to  produce  fatal  results.  We  meet  with  them  not  un- 
frequently  with  a  history  of  six,  ten  and  twenty  years  standing.  They 
occasionally  rupture  and  entirely  disappear  without  any  apparent 
cause  except  distension.  Indeed,  while  I  have  not  seen  enough  of 
them  to  enable  me  to  decide  that  point,  I  think  the  cyst  is  generally  so 
frail  that  it  would  burst  before  it  grew  to  great  dimensions. 

Treatment. 

As  this  tumor  sometimes  disappears  after  tapping,  is  monocystic  and 
contains  bland  unirritating  fluid,  there  is  much  less  danger  from  evacu- 
ating it  than  the  ovarian  cyst.  Upon  these  considerations  is  based  the 
practice  pursued  by  some  of  relying  on  tapping  as  a  remedy.  There 
are,  however,  so  few  instances  in  which  it  is  not  followed  by  a  reaccum- 
ulation  that  it  is  hardh^  worth  while  to  make  any  favorable  calcula- 
tions upon  it  in  this  respect.  Hence  the  operation  for  the  removal  of 
the  growth  should  be  the  prime  consideration.  The  exceptions  to  this 
rule,  would,  as  in  ovarian  disease,  depend  on  unusual  circumstances. 
In  making  up  our  judgment  as  to  treatment,  we  should  remember 
that  there  is  much  more  encouragement  to  resort  to  what  is  generally 
considered  palliative  measures  than  in  the  treatment  of  other  cystic 
tumors,  and  give  this  consideration  due  weight  in  deciding  the  matter. 


PAROVARIAN  TUMOR — TREATMENT. 


787 


Small  tumors  may  be  entirely  and  safely  cured  by  exposing  the  cyst 
by  an  incision  through  the  abdominal  walls,  evacuating  it,  stitching  it 


Fig.  305. 


Fig.  306. 


Enucleation  of  Cyst  of  the  Broad  Ligament. 


in  the  wound,  inserting  a  drainage  tube  and  allow  it  to  remain  five  or 
six  days,  in  which  time  the  cyst  is  obliterated.     Enucleation  is  much 


788  OVARIOTOMY. 

more  difficult  in  a  tumor  that  does  not  extend  above  the  iliac  fossa 
than  in  one  large  enough  to  produce  considerable  distension  of  the 
abdomen. 

The  operation  for  the  removal  of  the  cyst  differs  in  no  respect  from 
that  of  ovariotomy  except  that,  as  it  is  not  generally  pediculated, 
enucleation  becomes  necessary.  Of  course  when  there  is  a  pedicle 
which  can  be  ligated,  the  operation  is  identical  with  that  of  ovari- 
otomy. When,  however,  after  opening  the  peritoneal  cavity,  we  find 
the  base  of  the  tumor  embraced  wholly  or  in  part  by  the  fleshy  cover- 
ing derived  from  the  broad  ligament,  we  cannot  remove  it  without 
separating  this  enveloping  tissue  from  the  cyst.  These  fibrous  bands, 
and  the  thickened  peritoneal  covering  so  closely  adhering  to  the  tumor 
are  not  adhesions,  they  are  the  original  coverings  of  the  growth  and 
have  grown  with  the  tumor  sufficiently  to  retain  their  original  rela- 
tionship with  the  parovarian  neoplasm.  And  fortunately  they  are 
connected  with  the  cyst  proper  by  not  very  firm  connective  tissue 
which  permits  the  two  surfaces  to  be  separated  without  doing  violence 
to  either. 

It  is  probably  always  better  to  evacuate  the  cyst  by  means  of  the 
large  trocar  and  draw  it  through  the  external  incision  where  it  should 
be  securely  held  by  the  Nelaton  forceps  or  b}^  the  hands  of  an  assist- 
ant. Thus  brought  fully  in  view  the  operator  can  easily  see  the  upper 
edge  of  the  fibrous  covering.  The  separation  should  be  commenced 
pretty  high  up  on  the  cyst,  by  carefully  making  an  incision  through 
the  covering  around  the  entire  cyst.  The  touches  of  the  knife  should 
be  so  delicate  as  to  preclude  the  Avounding  of  tbe  cyst.  We  may  tear 
the  envelope  with  the  fingers  but  it  is  not  the  best  way  to  do,  for  one 
of  the  most  important  items  in  the  operation  is  to  preserve  this  cover- 
ing in  its  entire  extent  around  the  sides  of  the  tumor  to  and  beneath 
the  bottom.  After  the  circular  incision  is  made,  we  may  with  the 
handle  of  the  scalpel  turn  out  the  edge  of  the  enveloping  tissues  until 
a  start  at  enucleation  is  made.  Then  this  covering  should  not  be 
stripped  down  in  shreds,  but  the  finger  should  be  carefully  inserted 
between  the  two  surfaces  and  carried  all  around  the  sides  and  doAvn 
under  the  bottom  of  the  cyst,  when  the  latter  may  be  easily  lifted  out 
of  its  bed.  If  the  operator  is  successful  thus  far  the  peritoneum  is 
clean  and  has  been  subjected  to  the  least  possible  violence,  and  the 
cup-shaped  stump  from  which  the  tumor  has  been  enucleated  is  of 
such  a  shape  as  to  retain  all  blood  or  serum  that  may  flow  from  lacer- 
ated surfaces,  and  be  drained  through  the  external  wound.  The  free 
border  of  this  hollow  stump  may  be  brought  up  through  the  lower 
end  of  the  Avound  and  drained  by  a  glass  or  rubber  tube.  Of  course 
during  the  enucleation  the  peritoneal  cavity  should  be  well  guarded 
to  prevent  it  from  becoming  befouled.  While  it  is  probably  generally 
better  to  use  a  drainage  tube,  I  am  sure  it  is  not  always  necessary. 


PAEOVAEIAN   TUMOR TREATMENT.  789 

When  the  right  parovarium  is  the  seat  of  the  growth  the  vermiform 
process  and  the  csecum  are  generally  lifted  high  up  on  the  side  of  the 
tumor.  They  are  not,  however,  in  the  way  of  enucleation  done  in 
this  way,  and  do  not  require  separate  treatment. 

In  fixing  the  stump  in  the  external  incision  it  should  not  be  drawn 
through  the  wound  so  as  to  cause  any  tension,  as  ample  allowance 
ouo-ht  to  be  made  for  the  natural  shrinkage  in  retractions. 


CHAPTER    XLVIIL 

FALLOPIAN  TUBES. 

The  Fallopian  tubes  are  sometimes  absent;  this  is  the  case  gener- 
ally when  the  uterus  is  absent.  But,  according  to  Rokitansky,  they 
are  not  always  wanting  when  the  uterus  is.  One,  or  even  both  of 
them,  may  be  wanting  when  there  is  no  other  fault  in  the  genital 
organs.  Occasionally  they  are  met  with  of  diminutive  or  rudimentary 
size.  They  are  also  deformed,  having  two  sets  of  fimbrillse,  one  at  the 
end  and  the  other  nearer  the  uterus,  with  openings  at  both  places ;  or 
bifurcated,  the  branches  entering  the  uterus  at  different  points.  Or 
one  may  be  longer  than  usual,  and  enter  the  cervical  portion  of  the 
uterus  as  mentioned  and  described  by  Pole,  and  quoted  by  Scanzoni. 
They  are  often  displaced  with  the  uterus  and  with  the  ovaries,  and, 
with  the  latter  organs,  are  found  to  enter  into  the  formation  of  a 
hernia. 

Salpingitis. 

Salpingitis  is  by  far  the  most  important  as  well  as  most  frequent 
affection  of  the  Fallopian  tubes.  It  is  found  to  exist  in  two  different 
forms,  endo-salpingitis  and  mural  salpingitis.  This  last  is  often  asso- 
ciated with  perisalpingitis.  The  inflammation  of  the  mucous  mem- 
brane or  endo-salpingitis,  may  be  regarded  as  catarrhal  in  cases  in 
which  the  inflammation  is  mild  and  its  products  sero-mucous  and 
non-irritating  ;  and  gonorrheal  when  the  secretion  is  muco-purulent 
and  highly  poisonous.  I  think  we  should  hold  this  distinction  be- 
tween common  catarrhal  and  gonorrheal  inflammation  as  of  consider- 
able importance,  especially  on  account  of  the  prognosis.  There  is  a 
great  difference  in  the  intensity  and  extent  of  the  inflammation,  the 
catarrhal  being  very  much  less  intense  and  extensive  than  the  gonor- 
rheal. In  either  case  the  inflammation  extends  from  the  endometrium. 
The  catarrhal  arises  in  the  uterus  more  as  the  result  of  a  depressed 
condition  of  the  vital  forces,  while  the  gonorrheal  comes  from  an  active 
virus  applied  to  the  mucous  membrane  of  the  genital  passages  awak- 
ening an  inflammation  which  spreads  with  great  rapidity  and  inten- 
sity, and  in  subsiding  lingers  in  perpetuity. 

The  catarrhal  variety  probably  does  not  spread  beyond  the  tube, 
while  the  gonorrheal  poison  lights  up  inflammation  in  the  parts  con- 
tiguous to  the  fimbria,  the  peritoneum  and  ovaries,  and  probably 
-deeper  tissues.  When  the  tube  becomes  occluded  in  catarrhal  endo- 
salpingitis  the  thin  sero-mucous  collection  in  the  distended  tube  is 
called  hydro-salpinx,  while  the  collection  of  the  contents  of  the  tube 
in  gonorrheal  or  septic  inflammation  constitutes  pyo-salpinx. 


SALPINGITIS — SYMPTOMS.  791 

• 

I  have  seen  many  instances  in  which  I  believe  chronic  gonorrheal  or 
gleety  discharge  in  man  has  given  rise  to  salpingitis  in  the  female. 

In  mural  salpingitis  the  lumen  of  the  tube  is  greatly  increased 
and  the  walls  thickened.  On  the  external  or  peritoneal  surface  there 
generally  are  found  fibrinous  deposits,  some  large  and  some  small,  and 
occasionally  the  tube  is  bound  to  the  contiguous  surface  with  fibrinous 
bands.  The  vessels  become  distinctly  visible  and  the  color  of  the 
organs  brighter.  As  seen  in  the  patient  before  removal  they  are  often 
scarlet  red.  The  whole  organ  is  greatly  elongated  but  retains  its  tor- 
tuous character. 

Peri-salpingitis  may  accompany  either  of  the  above  mentioned 
forms  of  tubal  disease.  The  peritoneal  and  connective  tissue  around 
and  near  the  tube  may  become  inflamed  without  the  process  extend- 
ing to  a  great  distance  or  depth,  or  the  inflammation  may  involve  the 
whole  broad  ligament,  and  in  either  case  reach  the  ovary.  Peri-salpin- 
gitis connected  with  gonorrheal  inflammation  of  the  tube  is  doubtless 
often  caused  by  the  spilling  of  pus  from  the  extremity  of  the  tube,  and 
inflammation  may  extend  to  the  surrounding  parts  as  the  effect  of  con- 
tiguity. Until  recently  it  has  been  the  belief  of  the  profession  that 
the  Fallopian  tube  was  seldom  if  ever  inflamed  except  when  involved 
as  a  part  of  general  pelvic  phlogosis  ;  and  that  the  explanation  of  the 
chronicity  of  the  process  in  it  was  that  it  outlasted  the  more  extensive 
and  surrounding  inflammation.  This  is  undoubtedly  true  in  some 
cases  of  septic  pelvic  inflammation.  Now  the  opinion  seems  to  be 
forming,  if  it  is  not  so  formed,  that  the  tubal  inflammation  is  generally 
primary  and  independent ;  and  becomes  the  source  of  the  surround- 
ing disease — as  local  peritonitis  and  cellulitis. 

Symptoms. 

It  will  not  be  necessary  to  dwell  upon  acute  salpingitis,  as  it  is  gen- 
erally only  a  part  of  an  extensive  perimetric  inflammation  and  cannot 
be  separately  recognized.  There  are  in  fact  no  distinctive  symptoms 
of  simple  chronic  catarrh  on  the  tube.  When  however,  the  tube  is 
closed  up  so  that  the  secretion  is  retained,  the  bulk  of  the  tumor  re- 
sulting may  give  rise  to  symptoms  of  weight  and  pressure. 

In  pyo-salpinx  the  symptoms  are  generally  pronounced  and  persis- 
tent. A  sense  of  heat  and  burning  with  cramping  pains  or  severe 
aching  and  tenderness  is  felt  in  the  iliac  region  of  the  side  aff'ected. 
And  I  think  another  important  symptom  of  chronic  purulent  salping- 
itis is  recurrent  attacks  of  acute  perimetritis,  probably  the  effects  of 
the  poisonous  fluid  flowing  from  the  extremity  of  the  tube  upon  neigh- 
boring tissues.  The  pains  attending  the  tubal  inflammation  are 
usually  aggravated  by  the  approach  of  the  menstrual  period.  And 
Mr.  Lawson  Tait  believes  that  the  menstrual  flow  may  be  increased 
as  one  of  the  symptoms.     In  fact  the  generative  functions  are  deranged 


792  FALLOPIAN   TUBES. 

in  many  ways.  The  general  symptoms  are  those  of  nervous  prostra- 
tion, hysteria,  neuralgia,  despondency  and  even  deep  melancholia. 
Although  not  always,  there  often  are  anaemia  and  emaciation. 

Diagnosis. 

A  correct  diagnosis  by  ordinarv  methods  is  sometimes  impossible  ; 
occasionally,  however,  it  is  not  difficult.  "When  the  tube  is  only  mod- 
erately enlarged  and  not  indurated  it  is  very  difficult  to  distinguish, 
but  often  by  examining  the  patient  under  the  influence  of  anesthetics 
through  both  the  vagina  and  rectum,  we  may  trace  the  tube  down  the 
posterior  border  of  the  broad  ligament  into  the  cid  de  sac  behind  the 
uterus  as  a  soft  cord  resembling  a  small  intestinal  convolution,  some- 
times when  the  abdominal  walls  are  thin  by  bimanual  examination 
we  may  trace  its  course  along  the  surface  of  the  broad  ligament.  To  do 
this  the  finger  of  one  hand  in  the  vagina  should  be  passed  up  to  the 
brim  of  the  pelvis  and  swept  slowly  around  as  near  the  brim  as  possible 
from  before  backward  while  the  hand  above  presses  the  abdominal 
wall  as  near  as  possible  to  the  finger  tips  as  they  move  towards  the 
sacrum.  In  this  way  the  fingers  in  the  pelvis  may  often  feel  the  soft 
serpentine  tube  for  some  distance  along  the  side.  The  efforts  to  ap- 
proximate the  opposing  fingers  should  be  made  with  gentleness  and 
the  force  applied  slowly,  giving  the  fingers  time  to  appreciate  by  the 
touch  the  organs  they  pass  over.  If  the  tube  is  filled  to  any  extent 
by  pus,  blood  or  serum  so  as  to  make  a  tumor,  by  this  method  of  ex- 
amination they  will  be  pretty  certainly  detected.  Should  such  accu- 
mulation be  discovered  the  manipulation  of  them  should  be  very 
guarded  as  too  much  rudeness  may  rupture  the  sac  and  flood  the  ab- 
dominal ca\T.ty  with  pus  and  induce  severe,  if  not  fatal  peritonitis. 

In  addition  to  the  indistinctness  of  a  small  and  soft  tube  there  are 
three  other  important  conditions  not  infrequently  jDresent  that  render 
our  efforts  at  diagnosis  unavailing.  They  are  a  thick  layer  of  adipose 
matter  in  the  wall  of  the  abdomen,  a  hardness  and  unyielding  state 
of  the  abdominal  muscles,  and  the  adhesions  and  indurations  result- 
ing from  previous  inflammatory  attacks.  If  the  degree  of  one  or  all 
of  these  conditions  is  very  considerable  it  is  an  absolute  bar  to  a 
definite  diagnosis.  Then  the  question  as  to  the  propriety  of  an  ex- 
Ijlorator}^  incision  comes  up  for  decision.  This  question  will  occur 
only  in  cases  of  great  gravity  and  obstinacy.  If  every  rational  measure 
for  the  relief  of  the  patient  has  been  tried  and  failed,  while  she  is 
suffering  greatly  from  what  would  appear  from  the  symptoms  a  disease 
either  of  the  tube  or  ovary,  I  believe  the  risk  of  an  exploration  is 
justifiable  and  that  the  operation  is  demanded.  In  many  cases  it  is 
the  only  way  to  arrive  at  a  correct  diagnosis,  and  the  incision  may, 
by  extending  it,  serve  as  the  opening  through  which  extirpation  may 
be  effected. 


SALPINGITIS — TREATMENT.  793 

Prognosis. 

There  is  probably  not  yet  sufficient  accuracy  in  the  diagnosis  of 
salpingitis  to  enable  us  to  separate  it  from  inflammation  of  neighbor- 
ing organs  and  tissues,  or  to  distinguish  cases  in  which  it  is  simple  or 
complicated,  or  even  between  the  different  varieties  of  tubal  inflamma- 
tion. The  prognosis  would  vary  with  these  conditions  and  be  influenced 
b}^  their  uncertainties.  But  I  think  a  reasonable  prognosis  may  be 
founded  upon  general  principles,  by  considering  the  causes,  the  length 
of  time  the  case  has  withstood  judicious  treatment,  the  constitutional 
or  diathetic  state  of  the  patient,  her  ability  and  disposition  to  co-operate 
with  us  intelligently  and  faithfully  in  our  efforts  for  her  relief,  and 
her  possession  of  the  means  to  command  every  facility  for  appropriate 
treatment. 

When  comjDlicated  with  ovaritis  or  suppurative  cellulitis  the  prog- 
nosis would,  of  course,  be  greatly  modified  by  that  circumstance.  In 
the  simple  catarrhal  and  mural  varieties  the  prognosis  would  be  very 
much  more  favorable  than  the  gonorrheal  form.  Recent  cases  would 
be  more  favorable  than  those  of  long  standing.  Those  in  patients  of 
tuberculous  diathesis  or  anaemic  habit,  in  the  poor,  or  ignorant  who 
are  surrounded  by  adverse  circumstances  or  who  cannot  be  made  to 
appreciate  the  importance  of  following  out  the  treatment,  would 
necessarily  be  unfavorable. 

Most  of  all  we  should  apply  the  prognostic  test,  of  a  well  studied 
course  of  treatment  perse veringly  carried  out  for  a  sufficient  time  to 
be  assured  that  it  will  not  succeed.  Schroeder  says  in  the  twenty- 
ninth  volume,  second  part,  of  Archives  fiir  G-ynecologie,  that  there  are 
cases  in  which  the  contents  of  a  pyosalpinx  becomes  thick  and  re- 
mains in  the  tube  and  is  harmless. 

Treatment. 

The  almost  complete  monopoly  affected  by  surgeons  in  the  treat- 
ment of  chronic  salpingitis  is  not  an  unqualified  blessing.  Indeed  it 
is  quite  certain  that  the  loss  of  the  tubes  and  ovaries  by  surgical 
methods  is  in  many  instances  a  needless  sacrifice.  Patient,  careful 
and  protracted  treatment  will  often  cure  them  and  compensate  the 
woman  for  the  trouble  and  time  required  by  saving  those  valuable 
organs.  There  is  usually  insufficient  attention  given  to  general  treat- 
ment in  the  management  of  cases  of  chronic  inflammation  of  the 
tubes.  It  is  necessary  to  promote  the  vigor  of  the  nervous  and  vas- 
cular systems  by  improved  nutrition,  to  regulate  the  distribution  of 
the  blood,  to  excite  and  maintain  at  their  normal  degree  of  activity 
the  secretory  and  excretory  functions  by  exercise  and  food  that  have 
this  effect;  and  as  the  process  of  repair  is  slow,  plenty  of  time  is 
necessary  to  the  successful  treatment. 


794  FALLOPIAN   TUBES. 

It  will  be  readily  understood  by  the  reader  that  the  treatment 
adapted  to  salpingitis  is  the  same  as  that  required  for  inflammation  of 
the  ovary,  local  peritonitis  and  cellulitis.  After  the  acute  stage  of  any 
of  these  affections  has  passed  off  and  left  the  patient  so  prostrated  as 
to  oblige  her  to  keep  her  bed,  the  difficulties  of  the  case  will  be  in- 
creased to  a  great  degree,  and  every  effort  must  be  made  to  restore  her 
physical  energies  and  correct  the  habits  of  invalidism  to  which  she  is 
reduced.  While  in  some  cases  this  will  be  impracticable,  in  many  it 
may  be  accomplished ;  but  in  all  we  will  meet  with  many  difficulties. 
The  patient  has  perhajDS  contracted  the  habit  of  resorting  to  stimulants 
for  support,  to  anod3'-nes  for  rest  or  comfort,  to  laxatives  to  overcome 
constipation,  and  to  the  idea  that  she  "  cannot "  do  otherwise. 

One  of  the  first  things  to  do  is  to  induce  the  patient  to  agree  to  dis- 
cipline, and  accept  measures  that  will  result  in  a  change  of  all  the 
habits  impeding  her  progress  toward  recovery.  An  understanding  of 
this  kind  will,  in  the  majority  of  cases,  facilitate  the  management  of 
them  very  greatly.  But  it  will  require  constant  vigilance  and  much 
prompting  to  aid  the  patient  in  maintaining  her  resolution.  Patients 
who  are  laboring  under  great  nervous  prostration,  an  almost  neces- 
sary concomitant  of  weak  will  or  feeble  resolution,  cannot  be  man- 
aged on  a  better  jjlan  than  that  suggested  b}^  Dr.  Weir  Mitchell, 
and  now  familiar  to  the  profession.  The  main  items  of  it  are  isola- 
tion, absolute  rest,  simple  diet,  passive  exercise  by  the  use  of  massage 
and  electricity,  succeeded  in  a  gradual  way  by  active  exercise,  full 
diet,  and  exposure  to  the  open  air.  Of  course  this  treatment  will  re- 
quire an  intelligent,  faithful,  and  vigilant  nurse. 

In  the  more  acute  cases  massage  and  good  feeding  are  to  be  regu- 
lated according  to  conditions,  always  keeping  in  mind  the  necessity  of 
as  high  a  state  of  nutrition  as  practicable.  Medicines  are  not  to  be 
relied  upon  as  the  onlj^  means  to  effect  a  cure  of  chronic  salpingitis. 
Before  all  considerations  we  should  avoid  opium,  and  in  fact  all  ano- 
dynes as  much  as  possible,  and  never  continue  them  after  urgent  exi- 
gency has  passed  away.  The  habitual  use  of  laxative  medicines  is 
not  as  disastrous  as  that  of  anodynes,  but  is  sure  in  most  cases  to  affect 
the  process  of  digestion  badly.  A  healthy  laxity  of  the  bowels  may 
be  maintained  by  ventral  massage  and  the  systematic  use  of  fruits, 
vegetables,  and  bread  made  of  unbolted  flour.  A  special  study  of 
each  case  with  reference  to  the  adaptation  of  laxative  ingesta  will 
usually  enable  us  to  find  effective  articles  for  the  purpose.  The 
reader  will  find  the  subject  of  constipation  treated  in  a  more  extended 
form  in  the  general  treatment  of  uterine  disease  in  this  book. 

Pain  may  be  frequently  relieved  by  the  use  of  sinapisms,  cataplasms, 
friction,  liniments,  etc.  Both  physician  and  patient  should  regard  an 
anodyne  as  an  indulgence,  to  be  avoided  when  possible.  Of  course 
there  will  be  times  when  anodynes  and  laxatives  will  be  allowable. 


SURGICAL   TREATMENT.  795 

but  they  should  both  be  regarded  as  temporary  measures.  We  find 
indications  for  rest  and  the  free  use  of  anodynes  in  the  earlier  stages 
of  gonorrhoea!  or  septic  cases. 

Some  of  the  local  means  for  controlling  general  pelvic  inflammation 
will  expedite  the  cure  ;  such  as  large  hot-water  vaginal  douches,  gly- 
cerine-cotton tampons,  sitz  baths,  hot  poultices,  etc. 

Surgical  Treatment. 

After  the  failure  of  a  well-conducted  medical  treatment,  we  are 
forced  to  resort  to  surgical  means  for  the  relief  of  the  otherwise  in- 
curable patient.  The  surgical  procedures  suggested  are  dilatation  of 
the  tubes  by  an  appropriate  probe  or  catheter,  aspiration  for  serous, 
sanguineous  and  purulent  accumulation,  and  extirpation. 

Dilatation  of  the  tube  by  a  sound  introduced  through  the  uterus  is 
said  to  have  been  accomplished.  In  two  instances,  not  cases  of  salpin- 
gitis, I  have  passed  the  common  uterine  sound  through  the  tubes 
several  inches  into  the  abdominal  cavity.  But  this  kind  of  catheteri- 
zation or  probing  cannot  be  regarded  as  a  generally  practicable  remedy, 
at  least  in  the  present  state  of  our  knowledge  and  skill.  When,  how- 
ever, we  look  back  a  few  years  at  what  has  been  done  in  gynecological 
surgery,  we  may  well  be  encouraged  to  believe  that  this  may  become 
one  of  the  recognized  means  of  evacuating  Fallopian  accumulations. 

Aspiration  may  be  regarded  as  practicable  in  some  cases.  The  sub- 
ject of  aspiration,  however,  stands  more  in  the  position  of  a  suggestion 
for  the  treatment  of  exceptional  cases  than  as  a  recognized  and  com- 
mendable remedy  to  be  resorted  to  generally.  Judging  from  the 
benefits  resulting  from  aspiration  to  evacuate  accumulations  else- 
where, it  is  reasonable  to  expect  that  it  may  to  some  extent  supersede 
the  more  dangerous  operation  of  extirpation.  This  operation  may  be 
done  through  the  vagina,  rectum,  or  abdominal  walls.  Whenever  it 
can  be  reached — and  this  can  be  not  unfrequently  done — through  the 
vagina,  this  should  be  the  selected  way.  Aspiration  through  the  ab- 
dominal walls  is  dangerous  because  of  the  likelihood  of  pus  getting 
into  the  peritoneal  cavity. 

But  as  the  question  of  surgical  treatment  now  stands,  salpingotomy 
is  regarded  as  the  operation  verj'-  generally  to  be  preferred,  and  appli- 
cable to  most  cases.  I  need  only  refer  the  student  to  oophorectomy 
for  a  description  of  the  mode  of  operating  to  remove  the  tubes.  In 
fact,  I  would  expect  always  to  remove  both  ovary  and  tube  at  the 
same  operation. 

Theoretically  one  would  see  the  dangers  of  extra-uterine  pregnancy 
in  leaving  the  ovary  after  the  tube  was  taken  out.  When  the  opera- 
tion is  to  remove  a  tube  distended  to  any  considerable  extent  with 
pus,  blood,  or  serum,  the  operator  should  be  careful  to  place  two 


796  FALLOPIAN   TUBES. 

double  ligatures  around  the  pedicle  a  short  distance  from  each  other 
and  cut  between  them.  This  is  to  avoid  the  escape  of  the  pus  or  other 
contents  into  the  abdomen ;  and  for  the  same  reason  great  care  should 
be  taken  in  manipulating  the  tumor.  The  sac  is  often  so  thin  and 
frail  it  ruptures  by  slight  pressure.  Should  pus  gain  access  to  the 
peritoneal  cavity  great  pains  must  be  taken  to  cleanse  that  cavity. 
Warm  water  from  a  jjitcher  should  be  poured  through  the  wound 
until  the  pus  is  thoroughly  washed  out.  The  water  can  be  carefully 
sponged  out  until  all  is  removed.  The  process  of  removing  the  water 
may  be  facilitated  by  turning  the  patient  on  the  side.  When  it  is 
remembered  that  this  tube  is  sometimes  distended  to  the  size  of  a 
goose-egg,  these  precautions  will  appear  valuable. 

Hematosalpinx,  etc.    . 

A  collection  of  blood  of  considerable  size  is  sometimes  met  with  in 
the  Fallopian  tubes.  Sometimes  it  is  so  great  as  to  give  much  incon- 
venience from  pressure  upon  the  surrounding  parts  and  a  sense  of 
distension.  Such  collections  may  constitute  a  part  of  hematometra 
from  retained  menses.  In  this  connection  the  blood  is  probably  forced 
into  the  tubes  by  the  resistance  of  the  distending  uterus,  and  will  gen- 
erally be  evacuated  when  that  organ  is  emptied.  In  other  forms  of 
hemato-salpinx  both  ends  of  the  tubes  are  closed.  The  most  plausible 
explanation  of  the  accumulation  is  that  the  blood  escapes  from  the 
lining  membrane  of  the  tubes  something  in  the  same  way  that  it  is 
extravasated  through  the  mucous  membranes  of  the  uterus.  The 
blood  of  hemato-salpinx  is  sometimes  coagulated,  more  frequently  it 
is  thin,  flowing  easily  when  the  cavity  is  opened.  One  would  suppose 
that  in  this  liquefied  form  it  was  absorbable  and  susceptible  of  spon- 
taneous disappearance. 

The  diagnosis  and  treatment  are  the  same  as  those  of  hydro-sal- 
pinx. 

The  tubes  are  doubtless  the  channel  through  which  inflammation  of 
the  uterus  finds  its  way  into  the  peritoneal  cavity,  and  also  the  con- 
duit for  fluids —  pus,  blood,  mucus,  etc. — from  the  uterus  to  the  peri- 
toneal cavity.  As  they  are  not  seldom  found  dilated  so  as  to  adniit  a 
uterine  sound  to  pass  them, — Hildebrant,  Matthew  Duncan,  Thomas 
Budd,  and  others,  have  seen  and  diagnosticated  dilatation  of  the 
Fallopian  tube  during  life, — we  need  not  be  surprised  at  the  transi- 
tion of  fluids  through  them  in  both  directions.  Thus  the  serous  con- 
tents of  the  peritoneal  cavity  may  be  passed  into  the  uterus  and 
vagina.  The  reader  will  not  fail  to  see  the  importance  of  diseases  of  the 
tubes,  on  account  of  the  sterihty  that  would  result  from  obliteration 
or  constriction  of  them,  or  the  danger  from  a  too  free  communication 
between  the  peritoneal  sac  and  the  uterine  cavity. 


HEMATO-SALPIXX,    ETC.  797 

Cancer  and  tubercles  of  the  Fallopian  tubes  are  not  often  observed  in- 
dependent of  the  existence  of  the  same  disease  in  the  surrounding 
tissue.  They  are  generally  though  not  necessarily  involved  in  cancer- 
ous degeneration  of  the  ovary  and  the  uterus. 

Hypertrophy  and  Atrophy  of  them  accompany  the  same  changes  in 
the  uterus.  They  are  enlarged  when  the  uterus  is  by  tumor,  inflam- 
mation, congestion,  or  pregnancy,  and  become  atrophied  as  the  uterus 
diminishes  in  size,  in  old  age  or  from  any  other  cause.  Dropsy  of  the 
tubes  is  occasionally  observed. 

We  also  meet  with  small  serous  cysts  attached  to  the  fimbriated  ex- 
tremity of  the  Fallopian  tube.  They  are  usually  small  cysts,  distended 
by  serum,  scarcely  ever  exceeding  the  size  of  the  finger's  end. 


CHAPTER  XLIX. 

COCCYGODYNIA,  COCCYALGIA. 

Neuralgia  of  the  Coccyx. 

These  terms  are  used  to  denominate  one  of  the  several  peculiar 
neuroses  of  the  pelvic  organs,  especially  those  situated  at  the  hottom 
of  the  excavation.  It  belongs,  I  think,  clearly  to  the  same  class  of 
cases  as  vaginismus,  urethrismus,  spasm  of  the  bladder,  rectum^  etc., 
and  is  purely  a  nervous  affection. 

They  are  all  peculiar  hyper8esthesias,and  sometimes  have  a  demon- 
strable basis  of  excito-motor  origin,  as  fissures,  ulcers,  inflammation, 
etc.,  while  in  other  instances  there  seems  to  be  no  material  change  in 
any  of  the  organs. 

That  coccygodynia,  like  vaginismus,  is  often  associated  with  uterine 
disease,  disease  of  the  rectum,  bladder,  urethra,  etc.,  is  certain  from 
observation.  Whether  these  more  common  affections,  after  continu- 
ing a  long  time,  may  excite  the  nerves  into  a  state  of  instability  that 
becomes  permanent  or  not,  is  a  question  worth  asking  in  this  connec- 
tion. In  common  with  other  nervous  affections  having  a  reflex  ori- 
gin, may  not  the  symptoms  become  a  disease,  and  remain  an  indepen- 
dent affection  after  the  excito-reflex  cause  has  been  removed  ?  The 
irritation  so  protracted  and  unremitting  I  think  may  and  often  does 
induce  organic  change  in  the  nerves  or  the  subordinate  centres  with 
which  they  are  connected,  and  thus  perpetuate  the  symptoms. 

Structure  Affected. 

There  was,  in  all  cases  I  have  examined,  room  to  doubt  the  exact 
tissue  affected,  whether  in  the  periosteum,  interosseous  ligaments, 
muscles,  or  nerves. 

Symjptoms. 

Pain  on  moving  the  coccygeal  bone,  in  sitting  down,  rising  up, 
passing  the  fseces,  coughing,  sneezing,  walking,  or  standing.  In  bad 
cases  the  patients  are  not  able  to  sit,  stand,  or  walk  without  great  dis- 
comfort, and  are  so  pained  by  the  sitting  or  erect  posture  that  they 
are  confined  to  recumbency. 

They  thus  lose  their  general  health  and  become  permanent  invalids. 
This  is  very  rare,  however,  and  the  most  of  the  cases  we  meet  with 
are  in  patients  who  enjoy  a  tolerable  state  of  general  health,  but  are 
continually  annoyed  by  everything  that  causes  contractions  of  the 


DIAGNOSIS — PROGNOSIS TREATMENT.  799 

muscles  attached  to  the  coccyx  or  closely  connected  with  them.  They 
sit  on  one  side  of  the  buttocks  or  on  cushions  that  remove  the  pres- 
sure from  the  coccyx.  They  rise  to  the  standing  position  with  great 
care,  and  must  be  very  guarded  in  walking,  coughing,  or  sneezing,  etc. 

Diagnosis. 

This  is  made  by  considering  the  history  of  the  case  and  by  physical 
examinations.  The  finger  passed  into  the  vagina  or  rectum,  and 
pressed  backward  upon  the  coccyx,  so  as  to  move  it,  gives  the  patient 
great  pain.  Pressure  exerted  upon  the  posterior  surface,  with  suf- 
ficient force  to  move  it,  causes  even  greater  pain.  When  the  disease 
is  severe  the  suffering  is  so  great  that  it  is  with  difficulty  we  can  ex- 
amine the  coccyx  as  to  its  mobility. 

Dr.  Jenks  says  that  when  a  patient  is  examined  under  the  influence 
of  ether  the  muscles  connected  with  the  coccyx  are  relaxed,  while 
they  are  very  strongly  contracted  when  the  patient  is  not  etherized. 

Prognosis. 

There  seems  to  be  very  little  tendency  to  spontaneous  subsidence 
of  coccygodynia. 

The  menopause  does  not  affect  it  as  it  does  most  of  the  pelvic  dis- 
eases, and  it  is  often  a  long  time  after  the  change  of  life  before  the 
patient  recovers.  It  occurs  in  the  young  nuUiparous  and  parous 
-women  alike,  but  not  in  the  senile.  It  generally  causes  more  suffer- 
ing in  women  who  are  bearing  children. 

Treatment. 

The  palliation  of  the  symptoms  in  coccygodynia  consists  in  the 
use  of  anodynes  and  tonics,  the  former  to  relieve  the  great  suffering 
for  the  time.  They  may  be  used  in  suppositories  per  rectum,  per 
vaginam,  or  hypoclermically.  We  can  add' greatly  to  the  comfort  of 
the  patients  also  by  contriving  cushions  or  easy  chairs  for  them. 

A  tonic  or  roborant  course  of  treatment  will  sometimes  brace  up 
her  nervous  system  so  that  the  patient  can  bear  her  ills  without 
breaking  down  physically.  Among  the  means  to  accomplish  this 
end,  when  the  patient  is  not  too  bad,  travel  is  of  great  service,  a 
change  of  climate  from  hot  to  cold  in  the  summer,  and  from  cold  to 
warm  in  the  winter.  Quinine  and  iron  administered  internally, 
with  liberal  and  systematic  feeding,  contribute  to  the  same  purpose. 

In  the  earlier  periods  of  coccygodynia  we  may  hope  to  arrive  at  a 
cure  by  searching  for  and  removing  all  disorders  in  the  neighborhood, 
founding  our  treatment  upon  the  idea  of  removing  the  excito-reflex 
centre  of  disturbance. 

Dr.  Robert  Barnes,  of  London,  believes  that  it  is  caused  by  retro- 


800  COCCYGODYNIA — COCCYALGIA. 

versions  of  the  uterus.  Anal  fissures,  hemorrhoids,  ulcers  in  the 
rectum,  should  command  our  special  attention  if  they  exist,  and 
every  pains  should  be  taken  to  restore  all  deviations  from  general 
health. 

After  the  disease  has  existed  long  enough  to  become  an  indepen- 
dent affection,  probably  nothing  short  of  a  surgical  operation  will 
result  in  a  cure. 

To  the  late  Dr.  Nott  belongs  the  credit  of  first  describing  this  dis- 
ease and  devising  a  surgical  operation  for  its  cure.  He  called  it 
neuralgia  of  the  coccyx,  and,  after  trying  all  other  measures  that 
occurred  to  him,  extirpated  the  bone.  His  operation  consisted  in 
cutting  through  the  attachments  of  the  bone  on  each  side,  from  the 
base  to  the  apex,  everting  it  and  dislocating  it  from  the  sacrum. 

This  may  best  be  done  by  incising  the  integument  in  the  central 
line,  and  raising  and  turning  aside  the  flaps  until  both  margins  of 
the  bone  are  exposed.  The  next  step  is  to  cut  carefully  down 
through  attachments  at  the  point  of  the  coccyx  and  introduce  a 
blunt-pointed  bistour5%  or  the  point  of  scissors,  and  separate  the 
attachments  upward  to  the  base  on  both  sides.  The  bone  can  then 
be  lifted  up  and  turned  backward  to  expose  the  articulation,  which 
may  be  divided  by  a  bone  forceps  or  a  strong  knife.  The  loose  cel- 
lular tissue,  on  the  inner  surface  of  the  bone,  easily  gives  way  as  it  is 
lifted  from  its  bed,  or  may  be  divided  by  the  knife. 

There  is  generally  very  little  hemorrhage,  and  the  bleeding  will 
in  a  few  minutes  subside.  All  that  remains  to  be  done  is  to  close 
the  wound  by  replacing  the  flaps  and  joining  them  by  four  or  five 
stitches. 

This  is  neither  a  dangerous  nor  a  difficult  operation,  and  is  very 
effective  in  a  curative  point  of  view. 

In  1858  Professor  James  Y.  Simpson,  apparently  with  knowledge 
of  Dr.  Nott's  description  of  the  operation  for  this  affection,  published 
in  the  London  Medical  Gazette  his  Lectures  on  the  Diseases  of  Women, 
in  which  the  disease  is  recognized  and  his  operation  described.  His 
operation  consists  in  the  subcutaneous  division  of  the  connections  of 
the  bone  without  removing  it. 


INDEX  OF  AUTHORS. 


Abernethy,  -^04 

Adams,  J.  A.,  528 

Alexander,  W.,  511,  527,  528,  530,  534 

Allen,  E.  P.,  642,  646 

Allen,  J.  M.,  444 

Alquie,  528 

Amussat,  535 

Andrals,  271 

Anthony,  777 

Apostoli,  655,  656 

Atlee,  W.  L.,  619,  626,  663,  703,  721,  722, 

733,  747 
Atthil,  Lombe,  306,  629,  642,  643 
Aveling,  277 

Baker,  William  H.,  599,  600,  656 

Barbour,  42,  211 

Bardenhauer,  535 

Barker,  Fordvce,  193 

Barnes,  Robert,  135,  752.  799 

Battey,  Robert,  428,  673,  681,  687,  746 

Bandelocque,  550 

Banm,  606 

Beale,  L.  S.,  722,  723 

Beard,  352 

Beancliardat,  Madam,  550 

Becquerel,  394,  577 

Beers,  548 

Bengelsdorf,  628,  642 

Bennett,  J.  H.,  61,  355,  371,  387,  625,  719, 

721,  722 
Berniitz,  G.,  331,  461 
Billroth,  215,  606 
Bird,  Fred.,  715 
Bischoff,  207,  214,  510 
Bixbv,  G.  H.,  340,  342 
Bliss,  J.  C,  160 
Blunibach,  703 
Bogue,  697 
Boismont,  279 

Bozeman,  255,  270,  2"1,  272,  274,  278 
Brainard,  238 
Brann,  C,  114,  242 
Breisky,  507 
Brown,  654,  656 
Brown,  J.  B,,  241,  242,  243,  662,  714,  721, 

728,  733,  739,  743,  748 
Brvant,  137 

Buckingham,  C  E.,  631,  642 
Buoklev,  234 
Bndd,  il6,  796 
Budge,  277 
Budin,  102 


Bnrnham,  673 

Butlin,  608 

Buttles,  424,  434,  439 

Bvford,  513,  519,  535,  642.  74%  747 

Byrne,  John,  504,  594,  598 

Campbell,  H.  J.,  515,  776 

Carlet,  655 

Cazeaux,  386 

Chadwick,  49,  303,  621 

ChamberJin,  328 

Chambers,  328 

Chantreuil,  32 

Charpentier,  169,  193,  194 

Chiari,  746 

Chrobak,  629,  642,  643 

Clay,  J.,  580,  585,  673 

Cornil,  593 

Coste,  312 

Costilhes,  386 

Courtv,  519 

Cowan,  George,  631,  642,  643 

Cranda",  J.  P.,  638 

Croft,  235 

Crosse,  546 

Cutter,  449,  507,  508,  522,  644,  656 

Czerny,  535,  603 

Danvou,  386 

Davis,  R.,  746 

Dean,  H.  W,  631,642 

Dewees,  153,  154,312,  370 

Dieffenbach,  509 

Dieulafoy,  "36 

Donaldson,  S.  J.,  524 

Drvsdale,  T.  M.,  720,  723,  726 

Dudley,  E.  C,  440 

Dumas,  188 

Dumont-Pallier,  506 

Duncan,  John,  206,  211,  449,  522,  536 

Duncan,  J.  Matthews,  171,  206,  211,  448, 

796 
Dunglison,  385 

Emmet,  T.  A ,  124,  205,  211,  214,  231, 
240,  254,  255,  257,  258,  262.  263,  320, 
383,  435,  437,  439,  440,  449,  666,  667 

Engert,  116 

Engelman,  114,  277,  444,  516 

Erich,  124 

Esmarck,  672 

Etheridge,  J.  H.,  630,  631,  642 

Eiistache,  772 


51 


802 


INDEX    OF    AUTHOES. 


Fisher,  631,642 

Fitch,  T.  D.,  114,  307,  470,  519,  523 

Fitz,  340 

Foster,  42 

Fowler,  500.  523 

Fox,  W.,  640 

Freund,  William  A.,  21,  25,  2^=!,  202,  207, 

208,  210,  211,  214,  601,  603,  605 
Fricke  509 
Fritsch,  509,  510,  523,  604 

Garrignez,  27 

Gehrun.a,  512,  522 

Gferardin,  509 

Gillette,  124,  483 

Gilraore.  J.  F.,  746 

Gluge,  721,  722,  723 

Goodell,  304,  336,  436,  448,  449,  690,  746, 

747 
Goodman,  135,  231 
Goodrich,  G.  G,  327,  328,  635,  642,  645, 

646 
Gosselin,  386 
Gonpil,460,  461 
Gray,  52 

Green,  S.  W.,  699 
Greenhalgh,  422 
Gunn,  Moses,  631 

Hackenberg,  506 

Hacker.  671 

Hall,  Marshall,  482 

Hanks,  132,  306,  440,  475,  478,  522,  536 

Hart,  D.  B.,  23,  30,  42,  211 

Hatch,  550 

Hay,  Thomas,  557 

Hegar,  210,  449,  510,  670,  681 

Henle,  26,  29,  31 

Hennig,  535 

Herrick,  536 

Hewitt,  240,  512,  522 

Higbv,  120 

Hildebrandl,  628,  642,  646,  796 

Hillas,  Thomas,  757,  759 

Hodder,  E.  W.,  632,  642 

Hodge,  234,  366,  412,  500,  507,  521,  523, 

531,  536 
Holmes,  235 

Howard,  H.  C.,  630,  642,  646 
Hiigiiier,  146 

Hunter,  124,  313,  314,  327,  536 
Hyrtl,  52 

Jackson,  A.  R.,  135,  328,   537,  630,  642, 

643 
Jenks.  E.  W.,  114,  630,  642,  799 
Jewell,  J.  S.,  49,  352 
Jobert,  274 
Jukes,  633,  642 

Keating,  643 
Keith,  670 
Keith-Skene,  535 
Kelly,  H.  A.,  535 
Kemper,  160 


Kimball,  654,  656,  673 

Kinlock,  524 

Kiwisch,  733,  744,  745 

Kob,  758 

Koeberle,  535,  599,  600,  673 

Kuestner,  207,  211 

Kiister,  504 

Labb^,  Leon,  671 
Lahs,  759 

Lane,  L.  C,  601,  603 
Langenbeck,  214,  216 
Lazarevitsch,  509,  522 
Lebert,  702 
Lee,  733 
Lefort,  504,  511 
Leopold,  603 
Lewer,  137 
Lister,  770 
Loewenthal,  536 
Low,  J.  H.,  700 
Lnecke,  215 
Lushka,  22,  50 
Lusk,  736 

Mack,  340 

Mackintosh,  326 

Malgaigne,  509 

Martin,  A.,  202,  208,  217,  504,  510,  606 

Martin,  F.  H.,  655,  656 

Mason,  E.,  758 

Mayer,  506 

McClintock.  149,  544,  557 

McDowell,  750 

McLeod,  G.  H.  B.,  749 

Meigs,  142,  547,  548,  550 

Merriraan,  H.  P.,  631,  636,  642 

Meude,  509 

Meyerbeer,  606 

Miller,  117,  572 

Miller,  De  Laskie,  631 

Mitchell,  S.  W.,  352,  688,  694,  794 

Molesworth,  122 

Montgomery,  312 

Morris,  631^  642,  646 

Mueller,  P.,  505,  535,  603 

Munde,  124,  434,  436,  644,  673,  745,  746, 

757,  758 
Murry,  243 

Nfelaton,  444,  602 

Nelson,  120,  339 

Neugebauer,  L.  A.,  504,  511 

Nicholson,  757 

Noeggerath,  114,  116,  390,  391,  445,  745 

Nott,  120,124,800 

Nunn,  697 

Oldham,  312 
Olshausen,  535,  603 
Owen,  757 

Pajet,  702,  721 
Pall  en,  124,436 
Panas,  504 


INDEX   OF  AUTHORS. 


803 


Papin,  J.  L.,  230 

Paquelin,  749 

Parkes,  C.  T.,  671 

Parvin,  294 

Paulv,  707 

Pawlick,  137 

Pean,  601.  604,  670,  673 

Peaslee,  E.  R.,  306,  320,   3S5,   440,   500, 

506,  536,  703,  744,  748,  777,  779 
Pole,  789 
Polk,  517,  535 
Priestly,  509,  522 
Proctor,  736 
Puesch,  239 

Eanvier,  593 
Eeamy,  509,  510,  545 
Redner,  605 
Ricord,  234 
Rockwell,  A.  D.,  294 
Rokitansky,  703 
Roser,  507 
Russel,  633,  642 
Rutenberof,  135 
Rutgen,  188 

Savage,  28,  31,  41.  101,  102 

Sawver,  E.  W..  666 

Scanzoni,  148,  239,  312,  352,  507,744,745, 
789 

Schatz,  162,  166 

Schroeder,  C,  42,  504,  522,  524,  605,  606, 
670,  671,  673 

Schultze,  B.  S.,  26,  63,  86,  500,  507,  516, 
522  523 

Scott.  449,  450,  508,  509,  522 

Semeleder,  746 

Simon.  136,  264,  270,  327,  449,  475,509, 
510,  512,589 

Simpson,  Alex.  E.,  211 

Simpson,  vSir  James  Y.,  114,  154,  155,  289, 
295,  322,  326,  467,  571,  586,  587,  662, 
710,  718,  728,  732,  735,  740,  742,  743, 
800 

Sims,  J.  Marion,  56,  57,  58,  114,  120,  123, 
124,  133,  135,  154,  231,  233,  240,  241, 
242,  243,  251,  253,  258,  263,  265,  276, 
303,  318,  322,  326,  387,  425,  430,  446, 
449,475,482,  501,  503,  504,  513,  536. 
550,  664,  665,  727.  756 

Sims,  H.  Marion,  505,  523 

Skene,  135 

Smith,  Albert,  513,  514,  519,  523,  537 

Smith,  Heywood,  535 


Smith,  Tyler,  382,  550,  552,  556 

Southara,  733 

Spiegelberg,  396 

Squibb,  644,  645,  652 

Stoltz,  482 

Storer,  H.  R.,  146,  234,  235,  673 

Strange,  633 

Stratz,  577 

Stndley,  124,  523 

Sutton,  R.  S.,  668 

Tait,  196,  207,  211,  212,  215,  216,  477,  535, 
681,  690,  691,  693,  791 

Tarnier,  32 

Tavlor,  J.  E.,  430 

Thomas,  T.  G.,  30,  114,  116,  124,  304,  308, 
328,  500,  505,  507,  512,  513,  522,  524, 
538,  656,  666,  667,  673,  746,  796 

Thompson,  J.  H.,  633,  642 

Thornton,  782 

Tilt,  343 

Trenholme,  674,  675 

Trommhold,  7  16 

Veit,  253 

Virchow,  25,  331,  702 

Warn,  William  H.,  637 

Warner,  L.  F.,  398,  633,  642 

Wells,  Spencer,   670,  673.  703.   704.  727, 

736,  752,  754,  756,  773,  777,  779,  782 
Wernich,  644 
Werth,  504 

West,  158,  544,  546,  572,  712,  733,  744 
Wev,  W.  C,  632,  642,  644 
White,  Dr.  Carrie  N.,  531 
White,  J.  L.,  554 
White,  J.  P.,  434,  547,  548,  550,  552,  554, 

556,  629,  642,  643,  645 
Whitecomb,  757 
Whitehead,  380 
Wickersham,  560 
Williams,  John,  277 
Williams.  J.  F.,  622 
Wilson,  H.  P.  C,  598 
Winckel,  97,  135,  137,  146,  328,  510,  604 
Wing.  Clifton,  668,  746 
Woelfler,  671 
Wright,  M.  B.,  309 

Yarnell,  230 

Zwanck,  481,  507 
Zweifel,  202,  220 


GENERAL  INDEX. 


Abdomen,  gaseous  distension  of,  in  uterine 

disease,  354 
Abdominal  ovariotomy,  748 

pressure,  35,  38,  70,  81,  82,  170,  173, 
211,  487,  488 

section  for  uterine  displacements,  505, 
535 
Abortion,  339,  370,  379,  391,  487 

as  a  cause  of  subinvolution,  568 

of  uterine  displacements,  498 
Abscess,  aspirator  in,  478 

curetting,  475.  476 

diagnosis  of,.  727 

discliarging  into  bladder,  452 
into  rectum,  452,  453 
into  vagina,  452,  453 

due  to  cellulitis,  452 

to  hematocele,  333,  334 

indolent,  473,  478 

laparotomy  for,  476,  477 

operation  through  rectum,  475,  478 

pelvic,  342,  469,"478,  486 

treatment  of,  473 

with  pregnancy,  452 
Abscesses  of  the  labia,  144,  146 
Absorption,  summary  of  cases  of  fibrous 

tumors  cured  by,  641 
Accident  in  injection,  419 
Accidents  that  may  occur  during  ovari- 
otomy, 771 
Acid,  acetic,  731 

boracic,  500,  507 

carbolic,  154,  193,  196,  198,   221,  342, 
.426,  428,  531,  599,  751,  761,  762 

hydrocyanic,  154,586 

nitric,  156,  159,  276,  426,  731 

nitro-muriatic,  397,  731 

phosphoric,  225,  731 

sulphuric,  731,  408,  506 

tannic,  see  Tannin. 

vegetable,  226 
Actual  cautery.     See  Thermo-cautery. 
Acute  perimetritis,  451 
Adhesions  of  broad  ligaments,  528 

breaking  up  of,  5l6 

Fallopian  tubes,  528 

in  retroversion,  515 

laparotomy  for,  517 

omental,  766 

of  the  labia,  141 

of  ovarian  tumors,  764,  766 
Adhesions  of  uterus,  395,  472, 515,  517,  617 

visceral,  766 


Adjuster,  wire,  261 
Alcohol,  306,  474,  778,  783 
Alexander-Adams    operation.     See  Alex- 
ander's operation. 
Alexander's  operation  for  prolapse,  511 
after  laparotomy,  517 
for  retroversion,  527 
drainage,  531 
application,  533 
for  retroflexion,  536 
Aloes,  290,  293 
Alum,  245,  247,  251,  625 
Amenorrhoea,  282,  377,  399 

electricity  in,  294 

diagnosis  of,  286,  287 

from  ansemia,  292 

from  defective  nervous  energy,  294 

from  hvperinvolution,  570 

from  retention,  286,  728,  478 

in  inflammation  of  uterus,  424,  429 

ovarian,  690 

pathology  and    morbid    anatomy  of, 
283 

prognosis  of,  289 

symptoms  of,  283 

treatment,  290 
Ammonia,  aromatic  spirit  of,  548 
Ammonium  carbonate,  776 

chloride,  305,  626 
Ansemia  in  amenorrhoea,  292 

in  cancer,  575 

in  uterine  displacement,  499 

treatment  of,  403 
Anissthesia,  68,  94,  135,  256,  327,  550,  551, 
762,  776,  783 

examination  of  the  uterus  during,  65 

a   sympathetic   symptom    of    uterine 
disease,  361 
Anatomy  of  ovarian  tumors,  695 
Anatomy   and   physiology  of    the  female 

pelvic  organs,  17 
Anteflexion,  496 
Anteversion,  495 

pessaries,  512 

treatment  of,  512 
Antimony,  244 
Antipyrin,  783 
Antisepsis,  783 
Apostoli's  method,  655 
Arcus  tendineus.     See  White  line. 
Arsenic,  310,  402 
Arteries  of  the  pelvis,  palpation  of,  104 

vaginal  palpation  of,  105 


806 


GENEEAL    IXDEX. 


Ascites,  725,  750,  764 
Asclepias,  309 

Aspiration  of  Fallopian  tube,  795 
Aspirator,  478,  619,  719,  721,  795 
Atlee,  619,  663,  703,  720,  733 
Atresia  vaginae,  237 
Atrophy  of  the  Fallopian  tubes,  797 
of  the  mammary  glands,  343 
of  the  ovaries,  congenital,  682 
of  the  uterus,  acquired,  288 

as  a  result  of  inflammation, 

394 
congenital,  287,  343 
Atropia,  776 

Bag  of  waters,  162 

Baths,  415 

Battey's  operation,  673,  678 

physical  and  psychical  results  of, 
680 
Bearing-down  pain,  371 
Becquerel's  summary  diagnostic  between 
cancer  and  chronic  inflammation  of  the 
cervix,  394 
Beef-gall,  411,  412,  732 
Billroth  and  Leucke,  215 
Bimanual  palpation  of  the  uterus,  65 
Bischoff's  operation,  207,  214 
Bismuth,  402 

Bladder,  20,  23,  50,  64,  68,  87,  118,  135, 
140,  142,  173,  223,  235,  2ol,  275, 
330,361,  537,616,  732 

abscess  opening  into,  452,  467 

chronic  inflammation  of,  227 

danger  of  wounding,  449,  772 

diseases  of,  223 

displacements  of,  479 

distension  of,  223,  540,  728 

foreign  bodies  in,  234 

hemorrhage  from,  225 

hyperassthesia  of,  2i5 

in  diagnosis,  727,  735 

inflammation,  330,  422 

inversion  of,  235 

irritable,  225,  481,  494 

palpation  of  the  interior  of,  96 

paralysis  of,  223 

pressure  upon,  714 

relation  of  the  ureters  and  uterus  to, 
50 

relation  to  uterus,  31,  486 

separation  in  hyslerectomy,  602,  603 

stone  in  the,  231 

tenesmus,  296,  305,  540 

treatment  of  paralysis  of,  224 
Bloodvessels  of  pelvic  organs,  25,  51,  70, 

77,  80,  104,  143,  217,  298 
Bougies,  251 

Bowels,  sympathetic  disease  of,  354 
Bozeman's  method  for  vesico-vaginal  fis- 
tula, 271 

apparatus,  271 
Broad  hook,  Byford's,  530 
Broad  ligaments,  palpation  of,  81 
tumors  of,  784 


Bromide  of  potassium,  403,  626 
Buchu,  226,  229 

Bulb  retroflexion  pessary,  Thomas's,  537 
Bulbo-cavernosus.     See  Constrictor  cunni. 
Butlin,     histologic      distinction    between 

sarcoma  and  carcinoma,  608 
Buttles'  lancet-shaped  knife,  439 

uterine  scariflcator  and  leech,  427 
Byford's  broad  hook,  530 

dressing- forceps,  123 

finger-curette,  134 

operating  table,  57 

probe-pointed  scissors,  529 

retroversion     and    prolapse   pessary', 
519 

uterine  scissors,  441 
Byrnes's  cautery  battery,  595 

cautery  ^craseur,  595 

cautery  electrodes,  596 

Caesarian  section,  753,  759 

Calcium  salts,  626 

Calculus,  vesical,  231 

Calomel.     See  Mercury. 

Cancer  of  the  Fallopian  tubes,  797 

of  the  labia,  149 

of  the  uterus,  394,  572,  606 

curetting  for,  585,  589 

discharges  from,  574 

hemorrhage,  674,  578,  587 

epithelial,  591 

structures,  593 

thei'rao-cautery  in,  585 
Cancerous  cachexia,  575 
Cancroid  of  the  uterus,  ^90 
Cannabis  indica,  585 
Can thar ides,  157,  290 
Caput  succedaneum,  45,  162 
Carbonic  acid  gas,  586 
Caruncles  of  the  urethra,  157 
Catheter,  134,  135,  142,  198,  229,  239,  250, 
258,  261,  287,  338,  727,  480,  541, 
545,  618,  764 

Goodman-Skene's,  135 

Simon's  urethral,  136 

Siras's  sigmoid  self-retaining,  135 

Skene's  double  perforated,  229 
Catheterization  of  the  Fallopian  tubes,  796 

of  the  ureters,  136 

of  the  urethra,  134 
Cauterization  of  the  vagina  and   cervix, 

504 
Cautery  battery  (Byrne's),  595 

fecraseur,  595 

electrodes,  596 
Cavura  ischio-rectale.      See  Ischio-rectal 

vault. 
Cellulitis.     See  Pelvic  cellulitis. 
Central  ruptures  of  perineum,  169 
Cephalalgia  (sympathetic),  358 
Cervical  and  uterine  cavities,  length  of, 

117 
Cervicitis,  38S 

Cervix  uteri,  amputation  of,  448,  454,  597, 
600 


GENEEAL    INDEX. 


807 


Cervix  uteri,  cancerous  ulceration  of,  573 

characteristics  of,  59 

hypertrophy  of,  446 

inflammation   of,   387,  388,   392,  419, 
421,  437 

laceration  of,  61,  435 

location  of,  61,  62,  495 

of  child-bearing  woman,  59 

of  virgin,  59 

pregnant,  64,  335 

scarification  of,  424 

senile,  60 

stenosis  of,  431 

ulceration  of,  385,  394,  395,  481 
Chair,  Wilson's  opei-ating,  56 
Chambers's  bifurcated  stem-pessary,  328 
Chamomile,  730 
Champagne,  776 

Change  of  life,  343.     See  Menopause. 
Chassaignac's  fecraseur,  660 
Chian  turpentine  in  cancer  of  the  uterus, 

580,  585,  589 
Chloral  hydrate,  310,  403,  423,  647 
Chlorine,  "587,  731 
Chloroform,  154,  310,  586,  731,  758 
Choking  sensation  in  uterine  disease,  364 
Chronic  inflammation  of  the  bladdei",  227 

perimetritis,  469 

retrouterine  hematocele,  338 
treatment  of,  342 
Churchill's  tincture,  427,  439 
Cicuta,  585,  731 

Cinchona,  156,  293,  305,  306,  398,  473 
Circumdigitation  of  the  uterus,  95 
Clitoris,  hypertrophy  of,  159 
Cocaine,  195 
Coccyalgia,  798 
Coccygeus  muscle,  101 
Coccygodynia,  798 
Coccyx,  98,  99,  104 

excision  of,  800 

neuralgia  of,  798 

subcutaneous  division  of  connections, 
800 
Coffee,  776 
Collodion,  193,  509 
Colocynth,  413 
Colpocele,  182 
Colpotomy,  189 
Columba,  156,  293,  473 
Coma,  347 

Concealed  lacerations  of  perineum,  170 
Condylomata  of  the  vulva,  150 
Congenital  atrophy  of  the  ovaries,  682 
Connective  tissue,  23,  63,  171,   172,  384, 

448 
Connective-tissue  chamber,  23,  25,  35,  49, 
53,  92,  104,  384,  448.     See  Pelvic  con- 
nective-tissue chamlier. 
Constipation,  354,  405,  481,  494 
Constrictor  cunni  muscle,  111 

plane  of,  167 
Control  of  the  pelvic  floor  muscles  by  the 

will,  37,  85,  102,  186 
Contusions  about  the  bony-walls,  171 


Convulsions,  346,  347,  361 

syncopal,  356 
Copaiba,  229,  24-5,  248 
Copper  sulphate,  152 
Cornil  and  Eanvier,  593 
Cornus  florida,  412 
Corpus  uteri,  63 
Corroding  ulcer,  155 
Cough  accompanying  uterine  disease,  364, 

365 
Creasote,  248 
Crescent  operation,  204 
Emmet's,  205 
Cubebs,  229,  230 
Cupping,  305,  348 
Curette,  Byford's  finger,  134 

probe,  133 

sharp,  588 

Simon's,  588 

Thomas's  wire,  133 
Curetting  of  the  uterus,  133 

for  cancer,  585,  589,  595 

in  menorrhagia,  306 

in  pelvic  abscess,  465,  466 

for  subinvolution,  570 

exploratory,  133 
Cutter  pessary,  507 

Cystitis.     See  Inflammation  of  bladder. 
Cystocele,  182,  479,  480 
Cyst  of  ovary.     See  Ovarian  tumors. 


Deep  pelvic  fascia,  lacerations  of,  168 
Defecation,  painful,  347,  361,454 
Degrees  of  median  laceration  of  perineum, 

182 
Delayed  involution,  558 
Delirium,  346 

Delivery  after  perineal  incisions,  192 
Depressor,  Sims's,  124 
Dermoid  tumors,  697,  750 
Diagnosis  of  absence  of  the  vagina,  236 

acute  inflammation  of  the  unimpreg- 
nated  uterus,  347 

acute  vaginitis,  244 

atresia  vaginse,  237 

amenorrhoaa,  286 

between  cancer  and  chronic  inflam- 
mation of  the  cervix  (Becquerel's 
summary),  394 

of  cancer  of  the  uterus,  577 

cellulitis,  457 

chronic  inflammation  of  the  bladder, 
228 

chronic  ovaritis,  692 

chronic  perimetritis,  471 

chronic  retrouterine  liematocele,  341 

chronic  vaginitis,  246 

displacements  of  the  vagina,  bladder 
and  rectum,  480 

displacements  of  the  ovaries,  684 

diflerential,  of  ovarian  tumors,  723 

dysmenorrhoea,  309 

endocervicitis,  392 

epithelioma,  592 


808 


GEXERAL    IXDEX. 


Diagnosis  of  fibrous  tumors  of  the  uterus, 

617 
hyperinvolution  of  the  uterus,  570 
hypertrophy  of  the  cervix,  446 
inversion  of  the  uterus,  545 
lacerations  of  the  cervix  uteri,  438 
local  peritonitis,  463 
mecobranous  dysnienorrhcea,  313 
metatithmenia,  334 
obstructive  dysmenorrhoea,  316 
old    lacerations   extending    into    the 

rectum,  184 
ovarian  tumors,  714 
paralysis  of  the  bladder,  2"'3 
parovarian  tumors,  785 
perineal  and   pelvic  floor  lacerations, 
177 
by  rectal  palpation,  181 
by  inspection,  183 
lacerations  of  the  pelvic  floor: 

a.  of  the  anterior  edge,  184 

b.  of  the  levator  ani  proper,  185 
method  of,  186 

retention  of  menstrual  fluid,  288 

salpingitis,  791 

sarcoma,  608 

stone  in  the  bladder,  232 

subinvolution  of  the  uterus,  566 

submucous  inflammation  of  the  uterus, 
393 

tumor  of  the  broad  ligaments,  785 

uterine  disease,  392 

uierine  displacements,  495 

during  pregnancy,  541 

vaginismus,  242 
Diarrhoea  in  uterine  disease,  354,  355 
Diathesis,  hemorrhagic,  300 
Digital  eversion  of  the  vagina,  113 

examination  through  vagina,  58 

exploration  of  the  pelvic  roof,  67 
Digitalis,  302 
Dilatation  of  the  urethra,  233 

of  the  uterus,  128,326,433 
Dilator : 

Goodell's,  327 

Hanks's,132,  440,  475,  478,  536 

Hunter's,  312,  327 

Molesworth's,  131 

Peaslee's,  322,  440,  536 

Simon's,  327 

See  Tents. 
Diseased  deviations  of  involution  of  the 

uterus,  558 
Diseases   and    accidents  of  the  labia  and 

perineum,  141 
Diseases  of  the  bladder,  223 

of  the  vulva,  150 
Displacements  of  the  ovaries,  682 

of  the  uterus,  484 

of  the   vagina,   bladder  and   rectum, 
479 
Double  perforated  catheter   (Skene's),  229 
Douches,  vaginal,  415,  417 
Douglas,  folds  of,  18,  49 
Douglas  pouch.     See  Recto-uterine  pouch. 


Dover's  powder,  311 
Drainage  in  ovariotomy,  primary,  750 
secondary,  751,  782 

after  Alexander's  operation,  531 

in  hysterectomy,  602,  606 
Dressing-forceps,  Byford's,  123 
Dumont-Pallier  elastic  ring  pessary,  506 
Duvernev's  gland,  phlegmon  of,  144 
Dvsmenorrlicea,    308,    330,    339,  375,  615, 
626 

dilatation  for.  326,  329 

incision  for,  318,  326 

inflammatory  form  of,  310 
treatment  of,  310 

membranous,  312 

neuralgic,  308 

obstructive,  314 

ovarian,  690 

pessary  in,  317 

treatment  of,  309 
Dysuria,  347,  420,  453 

Ecraseur,  241,  446,  449,  547,  557,  659,  66Q, 
749 
Chassaignac's,  660 
Elastic   bag,   reduction  of  inversion   by, 

555 
Electricity  in  amenorrhoea,  294 

in  hyperinvolution  of  uterus,  527 

in  paralysis  of  bladder,  225 

in  menorrhagia,  305 

in  ovarian  tumors,  745,  777 

in  uterine    displacements,  501,    504, 

557 
in  uterine  fibroids,  654.  657 
treatment  of  fibrous  tumors  by,  654 
Apostoli's  method  of,  655 
Electrolysis.     See  Electricity. 
Elephantiasis  of  labia,  148 
Elongation   of    the   supravaginal   cervix, 

447 
Elytrorrhaphia  duplex  lateralis,  217 
Emmenagogues,  290 

Emmet's  knife    for  dividing  the  cervix, 
319 
method  of  passing  sutures,  214 
method  of  treating  chronic  inflamma- 
tion of  the  bladder,  231 
method  of  securing  the  twisted  ends 
of  silver  sutures,  219 
Endocervicitis,  387,  388,  393 

diagnosis  of,  392 
Endometritis,  387,  429 
Endosalpingitis,  790 
Endoscope,  Skene's,  136 
Enema,  413 

Entero-vaginal  fistula,  275 
Entero-vesical  fistula,  274 
Enucleation  of    cyst  of    the   broad    liga- 
ment, 785, 794 
of  tumors  of  the  uterus,  663,  767 
Enucleator,  Sims's,  664 
Epilepsy,  678,  692,  693 

hystero-,  356 
Episiorrhapliy,  509 


GENERAL    INDEX. 


809 


Episiotomy,  189 

Epithelial  cancer  of  the  uterus,  590 
Epithelioma,  590 
\  Ergot,  contraindicationp,  568 

corrective  treatment,  647 
\       different  preparations  of,  644 

in  delayed  involution,  560,  562 
>     in  inflammation  of  bladder,  230 
j    in  fibrous  tumor  of  the  uterus,  624, 627, 
663,  664,  666 

in  membranous  dysmenorrhoea,  314 

in  menorrhagia,  302,  305,  307 

in  paralysis  of  the  bladder,  225 

in  subinvolution,  568 

mode  of  using,  642 

modus  operandi,  647 
Etiology  of  uterine  disease,  389 
Excrescences,  urethral,  157 
Examination  of  tlie  female  pelvic  organs, 
53,55,  114,  138 

bimanual,  57,  59.  65,  68,  74,  77,  80,  93, 
94,  139,  228,472,496,  497 

difficulties  of,  69 

instrumental,  114 

manner  of  conducting,  138 

ovaries,  69,  72 

perineum,  108 

position  for,  56,  57 

precautions  necessary,  68 

preliminaries,  53 

through  rectum,  91,  96, 104 

uterus  during  general  anaesthesia,  65 

vaginal  orifice,  108 

vulval  orifice,  110 
Exsanguinification  of  uterine  tumors,  671 

Fallopian  tubes,  27,  67,  68,  330,  732,  789 
absence  of,  789 
aspiration  of,  795 
cancer  and  tubercles  of,  797 
catheterization  of,  795 
cysts  of;  797 
deformities  of,  789 
differentiation  of,  81 
dilatation  of,  795,  796 
dropsy  of,  797 
•      extirpation  of,  795,  796 
felt  through  rectum,  95 
hypertrophy  and  atrophy  of,  749 
inflammation   of,   690,   693,  790, 

796 
obliteration  of,  796 
palpation  of,  67,  68,  77 
positions  of,  68 
rudimentary,  789 
rupture  of,  239 
sounding,  116 
Female  pelvic  organs,  practical  observa- 
tions upon  tlie  anatomy  and  physi- 
ology of,  17 
instrumental  examination  of,  114 
Fibroid  polypus  of  uterus,  648 

tumors,  610 
Finger  curette  (Byford's),  134 
Fistula,  entero-vaginal,  275 


Fistula,  entero-vesical,  274 

recto-vaginal,  275 

urinary,  251 
Fitch's  sound,  114 

supporter,  505 

trocar,  765 
Flap  lacerations  of  perineum,  168 

operations  upon  perineum,  206 
Flattening  of  the  perineal  bodv  in  labor, 

163 
Flexions  of  the  uterus,  489 
Foetal  membranes,  161,  187,  188 
Folding  of  the  perineal   body  in  normal 

labor,  162 
Follicular  vulvitis,  152 

causes  of,  treatment,  152 
Forceps,  double  tenaculum,  121 

Nelaton's,  766 

vulsellum,  661 
Foreign  bodies  in  the  bladder,  234 
Freund's    modified  operation    upon    peri- 
neum, 208 

method  of  passing  sutures,  214 
Fricke  (episiorrhaphy),  509 
Fritsch's  needle-holder,  526 
Fuller's  earth,  505 

Gall-bladder,  772 

Galvano-cautery,  557,  594,  598,  749 

Gangrenous  vulvitis,  156 

Gastralgia,  353 

Gastro-hysterotomy,  735 

Gehrnng  pessary,  512 

Gelsemium,  293,  412 

Gentle  touch,  advantage  of,  67 

Gin, 291 

Glands  of  Naboth,  430 

Gleet,  790,  792 

Glycerin,    154,    157,   243.   425,  439,   474, 
499,  500,  506,  569,  587,  694,  795 
and  tannin,  243 
carbolized,  152 

Gonorrhcea,  151,  246,  349,  390,  445,  690, 
789,  790,  792,  795 

Goodell's  dilator,  327 

Goodman-Skene's  self-retaining   catlieter, 
135 

Goodman,  treatment  of  chronic  inflamma- 
tion of  the  bladder,  231 

Granular  cell  of  ovarian  fluid,  720 

Gray,  attachment  of  the  pyriforrais,  100 

Great  sacro-sciatic  foramen,  100 

Guarded  liook,  Sims's,  665 

Hsematocele,  chronic  retrouterine,  338 
peritoneal.     See  Metatithmenia,  330 

Hanks's  dilators,  132,  440 

Hart  and  Barbour,  207,  211,  212 

Heart,  palpitation  of,  383 

Hematometra,  796.     See  Metatithmenia. 

Hemato-salpinx,  796 

Hemorrhagia.     See  Metrorrhagia. 

Hemorrhage  from  the  bladder,  225 
after  the  cautery,  596,  597 
fiom  labia,  142 


810 


GENERAL   INDEX. 


Hemorrhage  in  ovariotomy,  750,  767,  769, 

777,  778,  779 
Hemorrhagic  diathesis,  300,  779 
Hemorrhoids,  370,  616,  800 
Hemostatic  forceps,  604,  605 
Hewitt  pessary,  512 
Higby's  speculum,  120 
Hip-bath,  228,  247,  290,  305,  311,  349,  416, 

420,  474,  694,  695 
Histologic   distinction    between    sarcoma 

and  carcinoma,  608 
Hodge's  closed-lever  pessary,  521 
Huguier's  gland,  abscess  of,  146 
Hunter's  dilators,  327 
Hydatids,  544 
Hydrate  of  chloral,  403 
Hydrocele,  labial,  146 
Hydrometra,  544,  72S 
Hvdro-salpinx,  791 
Hymen,  108,  109,  112,  139,  176,  ISO,  186, 

209,  236,  240,  241,  316,  509 
Hyoscyamus,  421,  585,  586,  731 
Hypersemia,  uterine,  383 
Hyperaesthesia,  360 

of  the  bladder  and  urethra,  325 
Hyperinvolution,  554,  570 
Hypernidation,  312 
Hypertrophied  labia,  147 
Hypertrophy  of  the  cervix,  446 

of  clitoris  and  nympha,  159 

of  Fallopian  tubes,  797 

of  ovaries,  682 
Hyrtl,  arteries  of  the  pelvis,  52 
Hysterectomy  for  cancer,  579,  600,  606 

for  displacement,  501 

for  fibroids,  668 

for  sarcoma,  609 

hemorrhage  after,  605 

sepsis  after,  605 

without  ligatures,  604 
Hysteria,  356,  361 
Hystero-epilepsy,  356,  691,  692,  693 
Hysterometer,  118 

method  of  applying,  119 
Hystero-neuroses,  386 
Hysteropathy,  350,  441,  691 

patiiology  of,  382 
Hysterophores,  505.     See  Pessaries. 
Hysterotomy,  549,  756 

for  cancer,  600,  665 

for  inversion,  549,  556,  557 
Hystero-trachelorrhaphy.        See  Trache- 
lorrhaphy. 

Ice-bags,  222 

Ice-bladder,  783 

Ice-cap,  Thornton's,  782 

Immediate  perineorrhaph)-,  194 

Indagation,  method  of  rectal,  91 

Indigestion,  242,  398 

Inflammation,  acute,  of  the  unimpregnated 
uterus,  346 
and  ulceration  of  the  cervix,  394 
chronic,  of  the  bladder,  227 
of  the  vulva,  150 


Inflammatory  form  of  dysmenorrhoea,  310 
Infundibulo-pelvic  ligament,  73 
Injections,  accidents  in,  419 

vaginal,  417 
Injuries  of  the  perineum  and  pelvic  floor. 

mechanism  of,  161 
Instrumental  examination  of  female  pelvic 

organs,  114 
Intramural  fibroid  tumors,  650 
Intraperitoneal  hematocele,  331 
Intra-uterine  pessary,  Simpson's,  295 

stem-pessary,  Jackson's,  536 
Inversion  of  the  bladder,  235 
of  the  uterus,  543 

mortality,  545,  546 
reduction  by  the  elastic  bag,  555 
statistics,  546,  557 
Involution  of  the  uterus,  500 
delayed,  558 

diseased  deviations  of,  558 
Iodine,  426,  427,  730,  737,  740,  741,  744 
tincture  of,   146,   247,   305,   33S,  427, 

428,  440,  466,  474,  740 
ointment  of,  228,  421 
Iodized  phenol,  428 
Iodoform,  195,  196,  198,  221,  505,  531 

gauze,  198,  530 
Ipecac,  311 

Iron,  224,  290,  293,  309,  402,  403,  409,  625, 
799 
by  hydrogen,  409 
perchloride,  587 
persulphate,  303,  429,  549,  589 
Quevenne's,  293 
sulphate,  409,  505 

tincture  of  the   chloride  of,  154,  155, 
156,   247,   306,  425,   429,  549,  589, 
731 
Irregular  lacerations  of  perineum,  169 
Irritable  bladder  and  urethra,  225 
Ischial  spine,  99 

Ischio-rectal   vault  or  fossa,   35,  41,  42, 
104,  122 

Jaborandi,  589 

Jackson's  intra-uterine  stem,  536 

Jalap,  337 

Jenks's  sound,  114 

Jewell,  J.  S.,  49,  352 

Juniper,  229 

Knife  for  scarifying  the  cervix,  424 
Kolpokleisis,  268 

Labbfe,   Dr.   Leon,   ex-sanguinification  of 

tumors  of  uterus,  671 
Labia,  abscess  of,  146 

absence  of,  149 

adhesions  of,  141 

cancer  of,  149 

diseases  and  accidents  of,  141 

elephantiasis  of,  148 

hemorrhage  from,  142 

hydrocele  of,  146 

hypertrophy  of,  147 


GENEEAL    IJSTDEX. 


811 


Labia,  oederna  of,  144 
plalegmon  of,  144 
sanguineous  infiltration  of,  143 
tnmors  of,  147 
varices  of  and  vulva,  153 
wounds  of,  142 
Lacerations  of  the  cervix  uteri,  61,  435, 
569 

complications,  437 

degrees,   localitv,   and   duration, 
436 
of  the  perineum   and  pelvic  floor,  43, 
113,  160 

preliminary  observations,  160 

mechanism  of,  161 

of  coccygeal  portion,  161 

of  obdurato  -  coccygeal    portion, 
162 

of  levator  coccygei,  163 

of  levator  ani  proper,  164 

of  levator  vagiuse,  164 

of  constrictor  cunni,  167 

of  vulva,  167 

of  trans  versus  perinsei  and  sphinc- 
ter ani,  168 

of  perineal  septum,  168 

of  deep  fascia,  168 

flap  variety  of,  168 

central,  169 

irregular,  169 

concealed,  170 
from  contusions  against  bony  wall,  171 
extending  into  rectum,  171 
immediate  efl'ects  of,  171 
remote  effects  of,  172 
effects  upon  uterus,  172 
effects  upon    bladder,    urethra,    and 

rectum,  173 
effects  upon  vagina,  174 
other  effects,  174 
symptoms  of,  174 
varieties  of,  175 
degrees  of,  176 
diagnosis  of,  177 
palpation,  180 
rectal  palpation,  181 
inspection,  183 
combined    palpation  and  inspection, 

184 
degrees  when  extending  into  rectum, 

184 
diagnosis  of  lacerations  of  pelvic  floor, 

185 
diagnosis  of  lacerations  of  deeper  por- 
tions of  pelvic  floor,  185 
metliod  of  diagnosis,  186 
prognosis,  187 
prevention,  187,  192 
colpotomy,  episiotomy,  189 
perineal  tenotomy,  190 
choice  of  methods,  192 
treatment,  193 

by  coaptation,  193 

immediate  perineorrhaphy,  194, 
498 


Lacerations,  treatment,  reasons  for  fsiilure, 
194 
contraindications,  194 
the  operation,  195 
extending  into  rectum,  199 
when  to  operate,  200 
method    of    restoring    the  perineum 
when  the  rectum  is  not  opened.   See 
Perineorrhaphy, 
with  lacerations  of  the  cervix,  437 
with  subinvolution,  569 
Laminaria  tents,  128,  129,  132,  231 
Langenbeck's  operation,  214 

serres-flne,  217 
Laparo-hysterectomy,  668 
Laparo-oophorectomy,  681 
Laparotomy  for    adhesions    in    displace- 
ments of  uterus,  517 
extirpation  of  tumors  of  uterus,  667 
Lard  enema,  732 
Lead  acetate,  151,  229,  245,  247 
Leeches,  337,  348,  423,  465 
Lefort's  operation  for  strengthening  pelvic 

roof  supports,  504,  510 
Leucorrhcea,  371,  379,  388,  392,  395,438, 

480,  545,  615,  628 
Levator  ani  muscle,  101,  108 

plane  of,  164 
Levator  vaginje,  plane  of,  164 
Lever  for  dilating  the  vagina,  126 
Lewer's,    Arthur,    method    of    exposing 

ureters,  137 
Ligaments,  palpation  of  the  ovarian,  72 
the  infundibulopelvic,  26,  70,  73 
palpation  of  the  I'ound,  74 
interuretric,  27,  68,  89,  90,  137 
of  uterus,  18,  66 
pubo-vesico-uterine,  18,  29,  448,  482, 

487 
sacro-uterine   or  posterior  suspensorv, 
18,  24,  29,  49,  68,  70,  75.  83,  86,  93, 
94,  107,  160, 161,  487,  489,  492,  493, 
494,496,511,512,517,524,527 
broad,  ligamenta  lata,  18,   24,  27,   53, 
69.  70,' 74,  76.  81,  82,  95,  107,  160, 
172,  173,  330,  472,  490,  493,  494, 
526,   690,   694,  768,  784,  789,  790, 
792 
round,  19,  27,  68,  74,  76,  84,  85,  172, 
488,  493,  510,  512,  517,  524,    525, 
534 
uterine.     See  Ligaments  of  uterus. 
Lime,  chloride,  157 
Lithium,  761 

Lithotomy,  Sims's  method,  233 
Lithotrity,  233 

Liver,  sympathetic  affections  of,  354 
Lobelia,  302 
Local  alteratives,  426 
congestions,  404 
peritonitis,  451,  460 
symptoms  of  uterine  disease,  369 
Location  of  uterus,  abnormal,  63,  64 

normal,  17,  63 
Lymphatics  of  the  pelvis,  25,  53,  68 


812 


GENERAL   INDEX. 


Lvttse,  tincture  of,  276 

Magnesia  citrate,  689 

sulphate,  408,  409 
Malgaigne,  509 
Mammary  bodies,  366 
Manner  of  conducting  an  examination  of 
pelvic   organs  in  making   a   diagnosis, 
138 
Martin's  modification  of  tlie  bilateral  opera- 
tion, 203 
Masturbation,  390 
Mayer,  elastic  ring  pessary,  506 
Mcintosh,  uterine  supporter,  508 
Mechanical  support,  517 
Mechanism  of  laceration   and  injuries  of 

the  perineum  and  pelvic  floor,  161 
Median  lacerations  of  perineum,  degrees 

of,  182 
Membranous  dysmenorrhcea,  312 
Menopause  and  senility,  343 
Menorrhagia,  297,  377 

from  nervous  influence,  296,  399 

during  lactation,  296 

effect  of  mammary  irritation,  296 

from  reflex  causes,  296,  297 

from  fibrous  polypus,  298 

from  inflammation,  298,  434,  472 

from  malignant  disease,  298 

from  uterine  displacement,  293 

from  tumors,  299,  472 

hemorrhagic  diathesis,  297 

treatment,  300 
palliative,  301 
curative,  304 
electricity  in,  305 
curetting  in,  306 

ovarian,  691,  693 

in  inversion  of  uterus,  545.     See  Me 

,  trorrhagia 

in  cancer,  574 
Menstruation,  276,  278,  330 

increased.     See  Menori'hagia. 

irregularities,  498 

misplaced.     See  Metatithmenia. 

rest  during,  448 

suppressed.     See  Amenorrhoea. 
Mercurv,  153,  247,  397,  427,  474,  626,  730, 
751,761 

blue  mass,  154,  276.  408 

bichloride,    196,   293,   305,   306,  337, 
398,  473,  646 

cathartic,  157,  408 

mild  chloride,  244,  311,  348,  689 

ointment,  150 

pernitrate,  428,  598,  600,  601 
Meso-aalpinx,  27 
Metatithmenia,  330 

diagnosis,  344,  458 

evacuation  of  blood  in,  337,  339 

prognosis,  335 

sepsis  in,  333 

symptoms,  336,  342 
Method  of  rectal  indagation,  91 
Metritis,  347 


Metrorrhagia,  296,  297,  429,  615,  624,  628, 
662 
in  cancer,  574,  678,  587 
in  delayed  involution,  559,  560.  562 
in  inversion  of  uterus,  544,   545,  547, 
549,  554 
Metrotome,  Peaslee's,  323 
Microscopic    examination    of    fluid  from 

ovarian  tumors,  722 
Misplaced  menstruation,  330 
Modified  Freund's  operation,  208 
Molesworth's  dilator,  131 
Moral  and  mental  derangement   (sympa- 
thetic), 357 
Mucous  inflammation  of  uterus,  387 
Multiparous  uterus,  appeai-ance  of,  126 
Mural  salpingitis,  790 
Muscles  of  pelvis : 

coccygeus,  32,  34,  35, 101,  103 
constrictor  cunni,  bulbo-cavernosus  or 
vulval   sphincter,  40,  43,111,    161, 
164,167,  180,  189,  191,  192,  200 
constrictor  urethra,  41 
gluteal,  32,  35 

internal  obturator,  32,  70,  103 
levator  ani,  29,  32,  33,  34,  35,  42,  90, 
101,   103,   104,   108,  110,  111,  162, 
164,  171,  174,   181,   185,   187,  189, 
195,  200,  210,  534 
levator  vaginae,  29,  34,  40,  42,  43,  90, 
92,  103,l04,  108,110,111,112,115, 
160,  161,   164,  166,  167,   168,  170, 
171,  180,   183,   184,   186,   191,   192, 
200,  201,204,205,211,242 
psoas,  70 
pvramidal,  32 
pyriformis,  35,  57,  99,   101,  103,   105, 

106,  108 
sphincter  ani,  41,  168,  172,   174,  180, 

181,  182,  210,  211,  221 
transversus  perinsei,  35,  41,  112,  165, 
166,  168,  180,  192 
Muscular  weakness  (sympathetic),  362 
Musculature  of  the  pelvic  roof,  19 

Naboth  glands,  430 

Needle  holder,  Fritsch's,  526 

N^laton's  forceps,  766 

Nelson's  speculum,  120 

Nerves   of  pelvis,  25,  53,  107,   294,  362, 

616 
Nervous  excitability,  401 

prostration,  390,  399 
Neuralgia  of  the  cervix,  798 
Neurasthenia,  352,  685 
Nidation  and  denidation,  277,  278 
Noma,  156 
Nott's  speculum,  120 

tenaculum  forceps,  124 
Nux  vomica,  409,  410,  411,  777 
Nymphn,  hypertrophy  of,  159 
Nymphomania,  678 

Oak  bark,  506 

Obstructive  dysmenorrhea,  314 


GENERAL    INDEX. 


813 


Obturato-coccygeiis.     See  Levator  ani. 
Obturator  internus,  103 
Occlusion  of  the  vagina,  141 
Oedema  of  the  labia,  144 
Oil,  almond,  250 

carbolized,  198,  775 

castor,  193,  198,  221,  761 

cod-liver,  247 

olive,  250 
Ointment  of  belladonna,  248,  411,  421 

calamine,  156 

chloroform,  154 

cicuta,  421 

carbolic  acid,  154 

hyoscvamus,  421 

iodine,  228,  421 

mercury,  421 

nut-gall,  248 

opium,  421 

oxide  of  zinc,  154 

tannin,  421 
Ointment  syringe,  421 
Oldham,  312 
Oophoralgia,  678 

Oophorectomy,  abdominal,  673,  681,  690, 
692,  693 

vagina],  681 
Oophoro-electrolysis,  745 
Oophoro-epilepsy,  678,  691 
Oophoro-mania,  678 
Oophoro-neuroses,  676,  686 
Operating  chair,  Wilson's,  56 

table,  Byford's,  57 
Operation,  Battev's,  673 

Bischoff's,  207 

Bozeman's,  for  vesico-vaginal  fistula, 
271 

crescent,  upon  perineum,  204 

Emmet's  crescent,  205 

flap,  206 

for   elongation    of    the   supravaginal 
cervix,  449 

for  retroversion,  525 

for  shortening  round  ligaments,  527 
sacrouterine  ligaments,  525 

Langenbeck's,  214 

ovarian.     See  Ovariotomy. 

Peaslee's,  in  obstinate  dysmenorrhoea, 
320 

Simon's,    for    vesico-vaginal    fistula, 
264 

Sims-Emmet  denudation  for  cystocele 
and  pi-ocidentia,  502 

Sims's,  for   dividing  straight  cervix, 
319 

Sims's,  for  vesico-vaginal  fistula,  255 

star,  upon  perineum,  205 

to  strengthen    or    elevate  the  pelvic 
roof  supports,  501 

triangular  flap,  upon  perineum,  206 

unilateral  flap,  upon  perineum,  209 
Operation    upon   uncicatrized    lacerations 

of  perineum,  210 
Operations,  plastic,  upon  the  perineum  or 
pelvic  floor,  509 


Opium,  199,  276,  301,  336,  348,  402,  420, 
421,  426,  465,  585,  587,  731,  776,  780 

extract  of,  151,  154 

tincture  of,  548 
Outlines  of  denudation    for    procidentia, 

510 
Ovarian  cell,  720 

irritation,  689 

ligament,  palpation  of,  72 

tumors,  695 
Ovaries,  383,  682 

absence  of,  289 

acute  inflammation  of,  688,  713,  793 

atrophy  of,  289,  343,  682 

ch]'onic  inflamation  of,  689,  712 

conditions    of,  causing  menorrhagia, 
296 

enlarge<l,  528 

extirpation  of.     See  Ovariotomy  and 
Oophorectomy. 

hernia  of,  684 

how  to  palpate,  69,  70,  71,  72 

hyperpemia  of,  690 

hypertrophy,  683 

ligaments  of,  26,  27,  70,  72,  77,  78,  81, 
82,95 

location  of,  25,  27,  69,  72,  82,  95,  96 

relations  of,  25 

table  of  positions,  72 
Ovariotomy,  abdominal,  748 

vaginal,  746 
Ovaritis,  acute,  688 

chronic,  689 
Ox-gall.     See  Beef-gall. 

Palpation  of  arteries  of  pelvis,  104,  107 
bimanual.      See    Bimanual  examina- 
tion of  ovarian  tumors,  716 
of  bladder,  96 
of  broad  ligaments,  81,  83 
of  coccygeus  muscle,  101 
of  constrictor  cunni,  111 
of  displaced  uterus,  63 
of  Fallopian  tubes,  77 
of  infundibulo-pelvic  ligament,  72 
of  ischial  spine,  99 
of  levator  ani  muscle,  101,  108, 110 
of  levator  vaginae,  108,  110 
of  obturator  internus,  10'2 
of  old  perineal  lacerations,  181 
of  ovarian  ligaments,  72 

tumors,  716 
of  ovaries,  69,  72 
of  pelvic  floor  and  perineum,  99 
of  pelvic  floor  through  rectum,  104 

nerves,  107 

roof,  58 
of  perineal  body  through  rectum,  113 
of  perineum,  108 
of  pregnant  uterus,  64 
of  pubic  fossa,  111 
of  pubo-vesico-uterine  ligaments,  86 
of  pyriformis  muscle,  99 
of  rectum,  91,  96 
of  round  ligament,  74,  76 


814 


GENERAL   INDEX. 


Palpation  of  sacral  promontory.  100 
of  sacro-sciatic  foramen,  100 
of  sacro-nterine  ligaments,  83 
of  small  sacro-sciatic  ligaments,  99 
of  transversus  perinsei,  112 
of  ureters,  7cS,  81 
of  uterus,  61,  90 
of  vagina,  88,  90 
of  vulval  orifice,  110 
Paquelin's  thermo-cautery,  594 
Paralysis  of  the  bladder,  223 

ergot  in,  22-5 
Parametritis.     See  Pelvic  cellulitis. 
Parametrium,  25,  86,  87 
Pareira  brava,  226,  229 
Parovarian    tumors,  784.     See  Tumor  of 

broad  ligament. 
Parturition  as  a  cause  of  disordered  invo- 
lution, 558,  567,  568 
of  laceration  of  cervix,  435 
of  perineal  lacerations,  160,  171 
of    uterine    displacements,   487, 

498,  511,  546 
of  uterine  disease,  389 
Pathology  of  hysteropathy,  382 

of  intraperitoneal  hematocele,  331 
of  periuterine  hematocele,  330 
Pawlick,  uretral  catheterization,  137 
Peaslee's  dilators,  440 

elastic  ring  pessary,  500,  506 
method  in  obstructive  dysmenorrhcea, 

320 
metrotome,  323 
Pelvic  cellulitis,  228,  274,  298,  348,  390, 
423,  437, 444, 451,  478,  699, 616,  692, 
790 
connective  tissue,  23 
connective-tissue  chamber,  23,  25,  35, 
49,  63,  92, 104,  384,  448 
Pelvic  fascise,  25,  32,  41,  86,  164,  168 
levator,  181 
perineal,  35,  41,  42,  43 
recto-vesical,  19,  28,  34,  41,  90 
Pelvic  floor,  18,  31,  32,  38,  98,  108,  160 
control  of  muscles  by  wiJ],  102 
diagnosis  of  lacerations  of,  177, 

184 
effects  of  lacerations  of,  171 
insufficiency, — requirements    for 

closing,  38 
mechanism     of  lacerations  and 

injuries  of,  161 
lacerations  of  perineum  and,  160 
operation  for  raising  the,  534 
outlet    or    insufficiency,    36,  38, 

39,  40,  43,  103,  484 
rectal  examination  of,  104 
relation   of  muscles   and    inter- 
posed tissues,  34 
relation  of  pelvic  roof  to,  32 
Pelvic  organs,  instrumental    examination 
of,  114 
percussion  of,  58 

practical  observations  upon  the 
anatomy  and  physiology  of,  17 


Pelvic  organs,  precautions  necessary  dur- 
ing examination  of,  68 
Pelvic  peritonitis,  228,  299,  390,  423,  437, 
444,  451,  460,  478,  599,  616,  692,  783, 
790 
Pelvic  roof,  digital  exploration  of,  67 
musculature  of,  19 
palpation  of,  58 
peritoneal  covering  of,  22 
plane  of,  31 

relation  to  the  pelvic  floor,  32 
starting  point  in  examining,  69 
Pepper,  black,  293 
Percussion  of  pelvic  organs,  58 
Perimetritis.     See  Pelvic  cellulitis. 
Perineal  bodv,  42,  43,  47,  92,   111,  112, 
113,  165,  170,  200,  205,  218 
characteristics  of,  43,  112 
flattening  of,  in  labor,  163 
folding  of,  in  normal  labor,  162 
measurements  of,  42 
rectal  palpation  of,  113 
incisions,  188 

after-management  of,  193 
choice  of  methods,  192 
delivery  after,  192 
lacerations,  effects  of,  171 
diagnosis  of,  177 
palpation  of  old,  180 
treatment  of,  193 
muscular  system,  39 
projection  or  area,  42 
rings,  162,  163,  167,  188 
septum,  41,  164,  168,  181,  182,  200 

lacerations  of,  168 
tenotome,  191 
tenotomy,  190 
triangle,"  40,  42,  181,  182 
Perineorraphy,  immediate,  191 
secondary,  199 
by  the  median  triangular  operation, 

200 
by  the  modified  triangular  operation, 

201 
by  the  bilateral  operation,  202 
by  Emmet's  crescent  operation,  206 
by  transverse  denudations,  205 
by  the  star  operation,  205 
by  the  triangular  flap  operation,  206 
by  BischofF's  operation,  207 
by  the  modified  Freund's  operation, 

208 
by  the  crescentic  flap  operation,  208 
by  the  unilateral  flap  operation,  209 
upon  uncicatrized  lacerations,  210 
for  lacerations  extending  a  short  dis- 
tance into  rectum,  210 
for  flap  operations,  211 
for    lacerations  extending    high    up 

into  rectum,  214 
choice  of  methods,  215 
preparation  of  patient  for,  216 
preparations  for  operating,  216 
operative  detail,  217 
sutures,  218 


GENERAL   INDEX. 


815 


Perineorrapliy,  the  quilled  suture,  219 
incision  of  sphincter  ani,  221 
after-treatment,  221 
for  prolapse,  449,  450,  481 
for  retroversion,  534 
Perineum,  18,  39,  46,  63,  108,  124,  160, 
245,  249,  254,  276 
as  a  support,  44,  160,  449,  450,  480, 

482,  483,  489 
in  labor,  45,  46,  160,  222 
operations  for  raising  the,  534 
tendinous  raphe  of  the,  43,  101,  112, 
113,  160,   164,  165,  166,  170,  171, 
176,  180,  182,  183,  191,  193,  200 
diseases  and  accidents  of,  141 
mechanism  of  lacerations  of,  161 
Perisalpingitis,  790 

Peritoneal  covering  of  the  pelvic  roof,  22 
Peritoneum,  pelvic,  22,  23 
Peritonitis,  local,  451,  459 

traumatic,  779 
Pessaries,  439 

Albert  Smith's  retroversion,  521 
barrier,  518,  520 
Byford's  anteversion,  513 

retroversion,  519,  520 
Byrne's  stem.  524 
cotton,  519,  537 
Courty's,  519 

Cutter's,  449,  507,  508,  522 
Donaldson's,  524 
Dumont-Pallier's    elastic   ring;     See 

Peaslee's 
egg  (Briesky),  507 
Emmet's,  522 
Fitch's,  T.  D.,  519,  523 

supyjorter,  505 
Fowler's,  500,  523 
Fritsch's    modification    of    Hodge's, 

523 
Gehrung's  anteversion,  512 

retroversion,  522 
Hewitt's  anteversion,  512 

retroversion,  522 
in  constipation,  412,  413 
in  dysmenorrhcea,  317 
in  menorrhagin,  307 
intrauterine,  295 

stem,  515,  536,  523.  524 

in  simple  dislocations,  499, 
500,  505,  509 
stem,  328,  445,  523,  524,  536,  537 
for  anteversion,  512,  514 
for  anteflexion,  537,538 
for  prolapse,  449,  481,  505,  509, 

511 
for  retroversion,  518,  524,  687 
Hodge's,  500,  507,  531,  536 
Jackson's  intrauterine  stem,  537 
Kinlock's,  524 
Lazarewitsch's,  509,  522 
Mayer's  elastic  ring.     See  Peaslee's 
Mcintosh's,  508 
Noegerath,  522 
Peaslee's  elastic  ring,  500,  507 


Pessaries,  Priestley's,  509,  522 

Roser-Scanzoni  hysterophore,  507 

Schroeder's,  522 

Schultze's  sleigh,  500,  507,  522 
figure-of-eight,  523 

Scott's,  449,  508^,  509,  522 

soft  rubber  inflated,  499,  506,  517,  544 

Simpson's  intrauterine  stem,  571 

Sims's,  523 

Studley's  retroversion,  523 

Thomas's,  500 

anteversion,  512 
modified  Cutter,  507,  508,  522 
bulb  retroflexion,  522,  537 
retroflexion,  523,  537 
stem,  524 

traction,  521,  522 

Zwank's,  507 
Phlegmasia  alba  dolens,  246 
Phlegmon  of  the  labia,  144 
Phosphorus,  309 
Physical  culture,  281 

Physiology  of  the  female  pelvic  organs,  17 
Pinhole  os,  376 
Piperine,  777 
Plane  of  the  constrictor  cunni,  167 

of  the  pelvic  roof,  31 
Plethora,  404 

with  amenorrhcea,  299 

treatment  of,  404 
Podophyllum,  413 
Polypoid  tumors,  removal  of,  658 
Position  for  Simon's  speculum,  57 

for  Sims's  speculum,  57 
Potassium,  626 

acetate,  311,  761 

bromide,  403 

caustic,  155,  600 

chlorate,  413 

iodide,  153,  229,  627,  646,  740 

nitrate,  151,  413 

permanganate,  229,  3^2 
Pouch,  para-vesical,  23.  50.  77 

recto-uterine,  22,  27,  48,  66,  73, 78,  93, 
339,  340,  341,  668,  687,  715,  718, 
728,751,782,792 

sacral-peritoneal,  23,  92,  93,  107 

vesico-uterine,  22,  86 
Poultices,  465,  795 

charcoal,  157 

mustard,  298 

yeast,  157 
Pregnancy,  289,  300,  724,  727 

and  cellulitis,  452 

baths  and  douches  during,  420 

extra-uterine,  335,  341,  795 

in  uterine  disease,  368,  389 

in  uterine  displacements,  486, 536,  539, 
542 

with  fibroid  tumors,  620,  621 

with  ovarian  tumors,  752,  759 

with  tubal  disease,  797 
Pregnant  uterus,  palpation  of,  64 
Preparation  of  room  for  ovariotomy,  761 

of  patient,  761 


816 


GEXEEAL    IXDEX. 


Preparation  of  snrgeon,  761 
Pressure,  abdominal,  35 

in  treatment  of  ovarian  tumors,  737 
Probe  curette,  133 

Procidentia,  outlines  of  denudation  for,  510 
Prognosis  of  atresia  vaginse,  238 

amenorrhcea,  289 

cancer  of  uterus,  578 

cellulitis,  459 

chronic  ovaritis,  693 

delayed  involution,  559 

displacement  of  ovaries,  685 

dysmenorrho3a,  309 

epithelioma,  593 

fibrous  tumors  of  uterus,  619 

inflammation  of  bladder,  228 

inversion  of  uterus,  546 

metatithmenia,  335 

obstructive  dysmenorrhcea,  317 

ovarian  tumors,  713 

perineal  lacerations,  189 

peritonitis,  local,  464 

salpingitis.  792 

sarcoma,  609 

subinvolution,  567 

urinary  fistula,  253 

vaginitis,  acute,  244 
chronic,  246 

vaginismus,  242 
Prolapse  and  procidentia,  487 
Prolonged  lactation,  480 
Pruritus  pudendi,  153 

treatment,  154 
Pubertv,  278 

Pubic  fossa,  111,  112,  117,  180,  181,  186 
Pubo-coccygeus.     See  Levator  ani. 
Puerile  anteflexion,  490 
Puerperal  state,  immediate  efl^ects  of  lacer- 
ations or  those  incident  to,  171 
Pyemia.     See  Sepsis. 
Pyo-salpinx,  791,  793 

Quassia,  156,  731 
Quilled  suture,  219 

Quinine,  151,  224,  301,  305,  309,  409,  568, 
780,  783,  799 

Bectal  examination  of  pelvic  floor,  104 
of  pelvic  roof,  90 
grooves.     See  Posterior  vaginal  sulci, 
indagation,  91.  96 
notches,  30,  109,  110,  186 
palpation,  181 

of  the  pelvic  arteries,  107 
of  the  perineal  bodv,  113 
promontorv,  33,  36,  42,  44,  47,  91, 185, 

211 
sphincter.     See  Levator  ani. 
Eectocele,  182.  414,  479,  483 
Eecto-vaginal  fistula,  249,  250,  275,  276 
grip,  95 

promontorv,    103,  109,  110,  181, 
185,  186,' 187,  535 
Keeto-vaginal  septum,  90,  92, 106, 176, 211, 
212,  214,  215 


Rectum,  29,  31, 33, 36, 42.  46,  52, 58, 59,  62, 
90,  93.  96,  107,  109,  112,  113,139, 
171,  172,  173,  176.  178,  182,  184, 
185, 199,  210,  215.  219  221,  222,  226, 
246,  247,  296,  305,  361,  370,  412, 
413,  421,  422.  466,  467,  616,  618, 
776,  778,  780,  792 
abscess    opening  into,  147,  452, 453, 

475 
dilatation  of,  475 
fissure  of,  243.  249,  800 
Eeduction  of  inversion  by  elastic  bag,  555 
Eeflex  symptoms  of  uterine  disease,  352 
Eepositor,  White's,  551 
Eetractors,  Simon's,  126 
Eetroflexion,  496 

during  pregnancy,  539 
Eetrouterine  hematocele,  338 
Eetroversion,  495 

during  pregnancy,  537 
Eheumatism.  246,  247 
Ehubarb,  409,  410 
Eound  ligament,  palpation  of,  74 
Eubber  coil,  787 
Eupture  of  cyst  of  broad  ligament,  785 

Sacral  promontory,  100 

Sacro-sciatic  ligaments,  99 

Sacro-uterine  ligaments,  shortening  of,  525 

vaginal  palpation  of,  83 
Salpingectomv,  795 
Salpingitis,  789,  790,  796 
Sanguineous  infiltration  of  labia,  143 
Sarcoma,  607 
Sarsaparilla,  153,  730 
Savage,  muscles  of  the  perineum  and  pel- 
vic floor,  35,  39 
plane  of  pelvic  roof,  31 
Savin,  290 

Scanzoni  pessary,  507 
Scarificator,  348,  424 
Scarifving  the  cervix,  424 
Schultze,  B.  S.,  figures,  488,  490,  495,  496 

sleigh  pessary,  507 
Sciatic  and  anterior  crural  nerves,  sympa- 
'      thetic  affections  of,  362 
j  Scissoi-s,  perineum,  216 
I  probe-pointed,  Bvford's,  529 

!  Scrofula,  246,  247 
:  Sea-tangle  tents,  128,  433,  618 
Secondary  perineorraphy,  199 

bilateral  operation,  202 

Martin's      modification 
of,  203 
median  triangular,  200 
modified  triangular,  201 
Senilitv,  342,  343 

Sepsis," 333,  342,  453,  466.   527,   641,  662, 
667,  727,  735,  790,  795 
after  ovariotomv,  750,  751,  755,  775, 

776,  781 
in  cancer,  575,  585,  592,  599,  605,  606 
Septicperaia,  781 
Serrated  spoon,  Thomas's,  666 
Serres-fines,  216,  217 


GENERAL,    lisDEX. 


817 


Seton,  228,  467,  474 
Sexual  iiitercoiirse,  excessive,  389,  390 
Sharp  curette,  588 
Shock,  544,  599,  605,  606,  778,  781 
Shortening  of  tlie  sacro-uterine  ligaments, 
525,  527 
dangers  of,  526 
Shower  bath,  417 
Silk  elastic  belt,  506 
Silver,  nitrate  of,  146,  152,   153,  155,  230, 

243,  245,  247,  250,  255,  426,  429 
Simon's  curette,  588,  589 

operation  for  elongation  of  tlie  supra- 
vaginal cervix,  449 
for  closing  the  vagina,  270 
for  vesico-vaginal  fistula.  264 
position,  57 
retractors,  126 
speculum,  124 
uretral  catheter,  136 
Simpson,  Sir  J .  Y.,  intrauterine  pessary,  295 

sound, 114 
Sims,  J.  Marion,  depressor,  124 
enuclealor,  664 
guarded  hook, 665 

method  of  examining  the  uterus,  127 
of  lithotomy,  233 
of  treating  chronic  inflammation 
of  the  bladder,  231 
operation  for  dividing  straight  cervix, 
319 
for  elongation    of  supra-vaginal 

cervix,  449 
for  vesico-vaginal  fistula,  255 
position,  58 

self-retaining  sigmoid  catheter,  135 
sound, 114 
speculum,  120,  123 
position  for,  57 
treatment  of  pruritus  pudendi,  154 
of  vaginismus,  241 
Sitz-bath.     See  Hip-bath. 
Skene's  endoscope,  135 

double  perforated  catheter,  229 
Slippery-elm  tent,  128,  130,  431,  591,  626 
Smitli's,  Albert,  retroversion  pessary,  521 
Sodium  salts,  626 

borate,  154,  225 
chloride,  413,  426 
nitrate,  413 
Sound,  uterine,  114 
Fitch's,  114 
Jenks's,  114 
mode  of  using,  117 
Simpson's,  ll4 
Sims's,  114 
Thomas's,  114 
Spasms  (sympathetic),  361 
Spaying,  673 
Speculum,  Higby's,  120 
Nelson's,  120 
Nott's,  120 
Simon's,  125 
Sims's,  120 
urethral,  135 


Speculum  examination  of  uterus,  120 
position  of  patient  for,  121 
mode  of  using,  12 
how  to  find  the  os  uteri,  123 
appearance  of  os,  125,  126 
color,  127 

indications  from  pus,  128 
conjointly  with  probe,  128 
with  hip-bath,  416 
Sphincter  ani,  lacerations  extending  into, 
168 
vagina,  164 
vulvae,  167 
Spinal  cord,  sympathetic  affections,  360 
Spleen,  enlai-gement  in    uterine    disease, 
355 
injury  in  ovariotomy,  771 
Sponge  bath,  417 
holders,  769 

tents,  128,  129,  231,  240,  303,  304,  445, 
570,  618,  621 
Squibb's  ergot,  644 
Stem,  Jackson's  intrauterine,  536 
Stenosis  of  the  cervix,  431 
of  the  external  os,  323 
of  the  internal  os,  322 
Sterility,  378,  379,  494,  571,  796 
Stillicidium  urinse,  540 
Stillingia,  153 
Stoniach,  functional  disturbance  of,  353 

sympathy  in  uterine  disease,  353 
Stone" in  the  bladder,  231 
Storer,  H.  E.,  abscess  of  labia,  146 
foreign  bodies  in  bladder,  234 
hysterectomy,  673 
Strychnia,  224,  230,  301,  309,  409,  410,  568 
Subinvolution,  511,  562 
Submucxjus  fibroid  tumor,  648 
Subperitoneal  chamber.      See  Connective- 
tissue  chamber, 
fibroid  tumor,  649 
Sulphur,  761 
Summary  of  cases  of  fibroid  tumors  cured 

by  absorption,  641 
Superficial  trachelotomy,  322 
Supporter,  Fitch's,  505 
Supports  of  uterus,  18,32 
Suppositories,  413 

Supravaginal  cervix,  elongation  of,  447 
Sutures,  218 

button,  271,  274 

catgut,  195,  197,  199,  219,  526,  5^0, 

671 
En)met's  method  of  passing,  214 
flap,  196 

method  of  introduction,  195,  197,  502 
quilled,  219 
removal  of,  198 
silk,  195,  197,  219,  266,  670,  671,  754, 

770 
silkworm-gut,    193,   195,     197,     198, 

199,  219,  5:i6,  530 
silver,  197,  219.  258,  263,  269,  270 
Sympathetic  or  reflex  symptons  of  uterine 
disease,  352 


52 


818 


GEXEEAL   IXDEX. 


Sympathetic  pains  in  the   pelvic   region, 

"361 
Syncopal  convnlsions,  356 
Syphilis,  151,  246,  247,  273,  452 

T  bandage,  304 

Table,  operating  ^Bvford's),  17 
Tactus  eruditus,  68 
Tait,  Lawson,  flap  stitch,  216 
Taraponment  vaginEe,  512 
Tampons  after  hysterectomy,  624 

after  menorrhagia,  303,  304 

after  metrorrhagia,  620 

after  ovariotomy,  750 

after  uterine  displacements,  495,  500, 
506,512,  514,  516,  519,537 

after  subinvolution,  569 

medicated,  516 
Tannin,  151,  154,  229,  243,  247,   248,  251, 

505,  506,  587 
Tapeworm,  223 
Tapping,  619,  735 

in  cyst  of  broad  ligament,  786 

in  ovarian  tumors,  732,  733,  735,  736, 
739,  744,  752,  756,  760.  765 
Taraxacum,  293 
Tarnier  and  Chantreuil,  32 
Taylor,  Isaac  E.,  430 
Tenaculum  forceps,  121,  124 

Nelson's,  121 
Tenotome,  perineal,  191 
Tenotomy,  perineal.  190 
Tents,  holder,  131 

laminaria,  129 

slippery-elm,  130 

sponge,  129 

tupelo,  128,  129,  132 
Thermo-cauterv,  156,  276,  585,  589,  594, 
598,  599,  668,  749 

dangers  of,  596 

Paquelin's,  594,  749 
Thomas,  T.  G.,  bulb  retroflexion  pessary, 
537 

pessary,  512 

serrated  spoon,  666 

sound, 114 

wire  curette,  133 
Thornton's  ice  cap,  782 
Tobacco,  infusion  of,  154 
Torsion  of  polypoid  tumors,  658,  661 

or  twisting  of  the  uterus,  493 
Touch,  advantages  of  a  gentle,  67 
Trachelorraphy,  440 
Trachelotomy,  superficial,  322 
Transverse  denudations,  205 
Transversus  perinsei,  112 

lacerations  extending  into,  168 
Traumatic  peritonitis,  777 
Treatment  of   accidents  that    may   occur 
during  ovariotomy,  771 

of  acute  inflammation  of  the  unim- 
pregnated  uterus,  348 

of  acute  vaginitis,  244 

of  adhesions  in  retroversions,  515 

of  amenorrhoea,  290 


Treatment  of  anteversions,  511 

of  atresia  and  absence  of  the  vagina, 

238 
of  cancer  of  the  uterus,  579 
of  chronic  inflammation  of  the  blad- 
der, 228 
method  by  Goodman,  231 
method  by  J.  L.  Papin,  230 
method  by  Sims,  231 
of  chronic  ovaritis,  693 
of  chronic  perimetriiis,  473 
of   chronic  retrouterine    htematocele, 

342 
of  chronic  vaginitis,  247 
of  coccygodynia,  799 
of  condylomata  of  the  vulva,  150 
of  delayed  involution,  559 
of  displacements  of  vagina,  bladder, 
and  rectum,  481 
of  ovaries,  685 
of  dysmenorrhcea,  309 
of  endometritis,  429 
of  entero-vaginal  fistula,  275 
of  entero- vesical  fistula,  275 
of  epithelioma  of  the  uterus,  594 
of  fibrous  tumors  of  uterus,  624 
by  electricity,  654 
by  enucleation,  663 
by  exsanguinification,  671 
surgical,  658 
of  follicular  vulvitis,  152 
general,  of  uterine  disease,  397 
of  inflammation  of  vulva,  151 
of   inflammatory  form  of  dysmenor- 
rhcea, 311 
of  inversion  of  uterus,  546 
of  laceration  of  the  cervix  uteri,  438 
local,  of  uterine  disease,  422 
of  membranous  dysmenorrhcea,  314 
of  menorrhagia,  300 
of  metatithmenia,  336 
of  neuralgia  of  the  coccyx,  799 
of  obstructive  dysmenorrhcea,  317 
of  ovarian  tumoi's,  730 
by  tapping,  732 
by  pressure,  737 
by  injection  of  the  sac,  740 
by  electrolysis,  745 
by  vaginal  ovariotomy,  746 
by    abdominal    ovariotomy, 

'748 
treatment  of  the  pedicle,  748 

the  ligature,  749 
after  ovariotomy,  774 
of  the  wound,  775 
of  the  vomiting,  776 
of  tiie  tympanites,  777 
of  tlie  hemorrhage,  778 
of  traumatic  peritonitis,  779 
of  septicEemia,  781 
of  parovarian  tumors,  786 
of  paralysis  of  the  bladder,  224 
of  perimetritis,  acute,  464 

ciironic,  473 
of  perineal  lacfei-ations,  193 


GENERAL    INDEX. 


819 


Treatment  of  puerperal  vaginitis,  244 
of  recto-vaginal  fistula,  275 
of  retroversions,  514 
of  retroversion    and   retroflexion  dur- 
ing pregnancy,  541 
of  salpingitis,  792 
of  sarcoma,  609 
special,  of  uterine  disease,  422 
of  stone  in  the  bladder,  233 
of  subinvolution,  567 
Triangular  ligament,  41,  43 
Trigone,  27,  51,  80,  81,  86,  87,  90 
Trocar,  338,  542,  619,  663,  736,  744,  745, 
753 
Fitch's,  765 
Wells's.  753 
Tubercles  of  the  Fallopian  tubes,  797 
Tuberculosis,  275,  285,  486,  797 
Tumors,  dermoid,  697,  747 

fibrous,  240,  307,  342,  472,   610,  612, 
674,  676,  678,  680,  715,  724 
origin  of,  610,  612 
fibrous,  of  ovary,  697,  714 

electrolytic  treatment  of,  654 
medical  treatment  of,  625 
nature  of,  612 
surgical  treatment,  659 
varieties  of,  611,  614 
of  broad  ligament,  341,  784,  789 
hydatid,  727 

ovarian,  332,  335,  341,  695,  724 
pelvic,  486 
Tupelo  dilators,  129 

tent,  128,  129,  132 
Turpentine,  229,  293 
Tympanites,  783 

after  ovariotomy,  777 


Uncicatrized   perineal  lacerations,  opera- 
tions upon,  210 
Unilateral  flap  denudations  of  perineum, 
209 

operation,  209 
Ureters,  after  death,  77 

catheterization  of,  136,  138 

diflerentiation  of,  81 

inflammation  of,  227 

palpation  of,  78,  81,  97 

relations  of,  27,  28,  68 
Urethra,  29,  30,  87,  90,  97,  135,  137,  142, 
158,  159,  198,  249,  252,  363 

caruncles  of,  157 

dilatation  of,  96,  233 

vascular,  158 
Urethral  excrescences,  157 

fossae,  29,  62,  89,  90, 185, 186,482,  502, 
503 

notches,  29,  30,  90,  109,  134,  185 

speculum  and  endoscope,  135 
Urethrocele,  479 
Uretral  catheter,  Simon's,  136 
Urinarv  fistula,  251 
Urine,  227,  228,  229 

decomposition  of,  224,  228 


Urine,  evacuation  of,  198,  221,  222,  224, 
243,  250,  347,  454,  466,  517 
fistula,  251,  275 
incontinence  of,  135,  225,  478 
retention  of,  223,  478,  481,  498,  540 
Uterine  disease,  general  consideration  of, 
350 
diagnosis  of,  389 
etiology  of,  389 

sympathetic  reflex  symptoms  of, 
353 
displacements,  484,  558 

anteversion,  487,  511,  616 
anteflexion,  484,  491 
retroversion,  413,  437,  447,  488, 

514,  616,  739 
retroflexion,  414,  437,  491,  493, 

723,  724 
lapse,  486,  500 
prolapse,  414,  437,  487,  501,  511, 

616,739 
protrusion.     See  Prolapse, 
latero-version,  472,  485,  488,  493 
latero-flexion,  493 
descent.     See  Lapse, 
procidentia.     See  Protrusion, 
torsion,  493 
ante-location,  487 
retro-location,  487 
latero-location.  487 
symptoms,  494 
causes,  486,  493 
what  constitutes,  486 
congenital,  492 
diagnosis,  495 
treatment,  498 

by  abdominal  section,  505 
by  cauterization,  504 
by  electricity,  501 
by   operations    upon    pelvic 
floor    and  perineum,  509, 
511 
by   operations   upon    pelvic 

roof  supports,  501,  505 
by  operations   upon    uterus, 

501 
by  tampons,  498,  499,  500 
flexions,  536 
hsematocele,  330 

manipulations  and  operations,    occa- 
sional outward  effects  of,  444 
probe.     See  Uterine  sound, 
scarificator  and  leech  (Buttle's),  427 
scissors  (Byford's),  441 
sound,  114,  393,  521,  724,  726,  732, 
735 
mode  of  using,  117 
object  in  using,  114 
size  and  length  of,  114 
supporter,  Mcintosh,  508 
tenesmus,  371 
Uterus,  abnormal  location  of,  63,  472.     See 
Uterine  dis]ilacements. 
abscence  of,  289 
acquired  atrophy  of,  288 


820 


GENEEAL   INDEX. 


Uterus,  acute  inflammation  of,   346,  389, 
392,  557,  560,  570 
of  mucous  membrane  of,  349, 

386,  387 
of  unimpregnated,  346 

adhesions  of,  395,  472,  617 

appearance  of,  in  the  aged,  126 
in  the  mnltiparous,  126 

atrophy  of,  289,  343,  394,  480 

bimanual  palpation  of,  65 

cancer  of,  394,  572,  606 

chronic  inflammation  of,  386,  434, 
514,  571 

circumdigitation  of,  95 

connected  with  ovaritis,  694 

delayed  involution  of,  558 

dilatation  of,  128 

displacements  of,  61,  64,  71,  73,  76, 
80,  81,82,  84,  85,  86,  89,  95,  139, 
172,  173,  315,  317,  335,  484,  557, 
687,  693,  723 

displacements  of,  as  a  cause  of  men- 
orrhagia,  298 

during  menstruation,  387 

eflfects  of  lacerations  upon,  172 

esamination  of,  during  anaesthesia,  65 
with  fiound,  114 

exploratory,  curetting  of,  13 

fibrous  tumors  of,  610 

hemorrhage.     See  Metrorrhagia. 

hypera>mia  of,  296,  298.  299,  311,  313, 
379,  383,384,  385,  569,  612 

hyper-involution  of,  570 

inflammation  connected  with  amenor- 
rha?a,  291,  292 

inversion  of,  543 

involution  of,  658,  571 

normal  location  of,  17,  63 

palpation  of,  63 

pregnant,  63,  335,  368.  See  Preg- 
nancy. 

relation  to  bladder,  31 

replacement  of,  514.  515,  541,  542, 
549,  557 _ 

subinvolution  of,  562 

tumors  of,  610 

ulceration  of.     See  Cervix. 
Uva  ursi,  226,  229 

Vagina,  28,  31,  87,  88,  95,   139,  173,  225, 

236,  448,  791  _ 
abscess  discharging  into,  452,  453 
absence  of,  237,  238 
affections  of,  236 
atresia  of,  237,  238 
digital  e version  of,  113,  182,  184 
examination  through,  58,  67 
displacement  of,  479 
efiects  of  lacerations,  160,    161,  174, 

437 
inflammation  of,  225,378,  390,  419 
occlusion  of,  141 
palpation  of,  88 


Vagina,  subinvolution  of,  480 

tumors  of,  240 
Vaginal  douches,  247,  41 5,  417,  694,  795 
injections,  417.    See  Vaginal  douches. 

accidents  in,  419 
orifice,  examination  of,  108 
ovariotomy,  746 
pack,  516 

palpation  of  pelvic  roof,  98 
of  pelvic  arteries,  105 
rings.     See  Perineal  rings, 
sphincter.     See  Levator  vaginfe. 
sulci  or  grooves,  anterior,   29,  87,  89, 
186,  482,  503 
posterior,    30,  90,   109,  185, 
186,  204 
tamponment,  5i2 
Vaginismus,  241 
Vaginitis,  225,  378,  390,  453 
acute,  243 
chronic,  245 
puerperal,  248 
Varices  of  the  labia,  143 

of  the  vulva,  143 
Vascular  urethra,  158 
Veratmm,  302,  349 
Versions  of  the  uterus,  487 
Vesical  calculus,  231 

Vesicovaginal  fistula,  227,  231,  249,  251, 
276 
Simon's  operation  for,  264 
Sims's  operation  for,  255 
Vesico-vaginal  septum,  22,  24,  86,  92,  97, 
138, 173,  227,   249,  250,  251,  275,  482, 
513,  514 
Viburnum,  309 

Vomiting  after  ovariotomy,  776,  779 
Voracity,  352 

Vulva,  condolymata  of,  150 
diseases  of,  150 
inflammation  of,  150 
treatment  of,  151 
Vulval  orifice,  examination  of,  110 
rings.     See  Perineal  rings, 
sphincter.     See  Constrictor  cunni. 
Vulvitis,  follicular,  152 
gangrenous,  156 

Weak  back  in  uterine  disease,  360,  370 
Wedlock,  294 
Wells,  Spencer,  trocar,  753 
White,  James  P.,  repositor,  551 
Wilson,  H.  C.  P.,  operating  chair,  56 
Winckel,  outlines  of  denudation  for  pro- 
cidentia, 510 

palpation  of  uretral  orifices,  97 
Wine,  338 
Wire  adjuster,  261 

curette  (Thomas's),  133 
Wounds  of  the  labia,  142 

Zwanck's  pessary,  507 


DECEMBER,  1887. 
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Roberts,  Surgery  of.         -  1.25 

Wood.     Brain  and  Overwork.     .50 


CHEMISTRY. 
Allen.     Commercial    Organic 
Analysis.  2d  Ed.  Volume  I.  4 

Volume  II.  -        -  5 

Volume  III.  -         — 


Bartley.     Medical. 

Bloxam's  Text-Book.     -  3 

Laboratory.  -  i 

Bowman's  Practical.      -  2 

LefFmann's  Compend.     -  i 

Muter.     Pract.  and  Anal.  2 

Richter's  Inorganic.        -  2 

Organic.        -        •  3 

Stammer.     Problems.     - 

Sutton.     Volum.etric  Anal.  5 

Thompson's  Physics.     -  — 

Tidy.     Handbook  of.        -  5 

Trimble.     Analytical.      -  i 
Vacher's  Primer  of. 

Valentin.     Qualt.  Analy.  3 

Award's  Compend.   -        -  i 

'Watts.     (Fowne's)  Inorg.  2 

(Fowne's)  Organ.  2 

Wolff.  Applied  Medical  Chem- 
istry.       ....  1.50 

CHILDREN. 
Chavasse.    Mental  Culture  of.  i . 00 
Day.     Diseases  of.   -        -  3.00 

Dillnberger.    Women  and.      1.50 
Ellis.     Mother's  book  on.  .75 

Goodhart  and  Starr.  3.00;  Sh.  3.50 
Hale.     Care  of         -        -  .75 

Hillier.     Diseases  of       -  1.25 

Meigs.      Infant   Feeding    and 

Milk  Analysis.         -        -  i.oo 

Meigs  and  Pepper's  Treatise. 5. 00 
Money.     Treatment  of.  -  3.00 

Smith.     Wasting  Diseases  of.  3.00 

Clinical  Studies.  -  2.50 

Starr,  Digestive  Organs  of        2.50 

COMPENDS 

And  The  Quiz-Cotnpends. 

Brubaker's  Physiol.    3d  Ed.  J!i.oo 


Fox  and  Gould.  The  Eye.  i.oo 
Horwitz.  Surgery.  3d  Ed.  i.oo 
Hughes.  Practice.  2  Pts.  Ea.  i.oo 
Landis.  Obstetrics.  3d  Ed.  i.oo 
Leffmann's  Chemistry.  i.oo 

Mason.     Electricity.        -  i.oo 

Potter's    Anatomy,   including 
Visceral  Anatomy.   117  lUus.  i.oo   i 

Materia  Medica.  4thEd.  i.oc   ' 

Roberts.  Mat.  Med.  and  Phar.  2.00 
Stewart,  Pharmacy.  2d  Ed.  i.oo 
Ward's  Chemistry.     2d  Ed.     i.oo 

DEFORMITIES. 

Churchill.     Face  and  Foot  3.50 

Coles.    Of  Mouth.  -  4.50 

Prince.     Orthopaedics.     -  4.50 

Reeves.  "  -  2.25 

DENTISTRY. 

Barrett.     Dental  Surg.   -  i.oo 

Flagg.     Plastics.      -        -  4.00 

Gorgas.     Dental  Medicine.  3.25 

Harris.     Principles  and  Prac.  6.50 

Dictionary  of.       -  6.50 

Heath.  Dis.  of  Jaws.  -  4.50 
Leber    and    Rottenstein. 

Caries.    ...        -  1.25 

Richardson.    Mech.  Dent.  4.50 

Stocken.     Materia  Medica.  2.50 

Taft.    Operative  Dentistry.  4.25 

,  Index  of  Dental  Lit.  2.00- 

Talbot.     Irregularities  of  the 

Teeth,     -        .        .        .         

Tomes.     Dental  Surgery.  5.00 

Dental  Anatomy.  

■White.    Mouth  and  Teeth.  .50 

DICTIONARIES. 
Cleveland's  Pocket  Medical.     .70 
Cooper's  Surgical.  -        -        12.00 
Harris'  Dental.        -        -  6.55 

Longley's  Pronouncing  -  i.oo 

DIRECTORY. 
Medical,  of  Philadelphia, 

Pa.,  Del.  and  South  N.  J.       2.50 

EAR. 
Burnett.     Hearing,  etc. 
Jones.    Aural  Surgery.     - 
Pritchard.     Diseases  of 
Randall  &  Morse.    Atlas. 
Woakes.     Deafness,  etc. 

Catarrh,  etc. 

ELECTRICITY. 
Althaus.  Medical  Electricity. g6. 00 
Mason's  Compend.  -  i.oo 

Reynolds.    Clinical  Uses.         i.oo 

EYE. 
Arlt.     Diseases  of.   -        -  2.50 

Carter.     Eyesight.   -        -  1.25 

Daguenet.  Ophthalmoscopy.  1.50 
Fox  and  Gould.  Compend.  i.oo 
Gowers.  Ophthalmoscopy.  6.00 
Harlan.     Eyesight.  -  .50 

Hartridge.     Refraction.  2.00 

Higgins.     Handbook.      -  .50 

Liebreich.    Atlas  of  Ophth.    15.00 
Macnamara.     Diseases  of       4.00 
Meyer  and    Fergus.      Com- 
plete Text-Book,  with  Colored 
Plates.     -        -        .         -  4.50 

Morton.     Refraction.  3d  Ed.    i.oo 


.50 
2-75 
1.50 
500 
1.50 


FEVERS. 
Collie,  On  Fevers.  -        -  2.50 

W^elch.     Enteric  Fever.  2.00 

HEADACHES. 
Day.     Their  Treatment,  etc.     1.25 
Wright.     Causes  and  Cure.        .50 

HEALTH  AND  DOMESTIC 
MEDICINE. 
Bulkley.    The  Skin.        -  .50 

Burnett.     Hearing.  -  .50 

Cohen.  Throat  and  Voice.  .50 
Dulles.     Emergencies.    -  .75 

Harlan.     Eyesight.         -  .50 

Hartshorne.    Our  Homes.        .50 

Hufeland.  Long  Life.  -  1.00 
Lincoln.     Hygiene.         -  .50 

Osgood.     Winter.    -        -  .50 

Packard.    3%a  Air,  etc.  .50 

Richardson's  Long  Life.  .50 

Tanner.     On  Poisons.     -  .75 

White.  Mouth  and  Teeth.  .50 
Wilson.     Summer.  -  .50 

Wilson's  Domestic  Hygiene,  i.co 
Wood.     Brain  Work.      -  .50 

HEALTH  RESORTS. 
Madden.     Foreign.  -  2.50 

Packard.  Sea  Air  and  Bath'g.  .50 
Solly.     Colorado  Springs.  .25 

HEART. 

Balfour.     Diseases  of     -  5.00 

Fothergill.     Diseases  of.  3.50 

Sansom.     Diseases  of.     -  1.25 

HISTOLOGY. 

{See  Micoscope  and  Pathology. 

HOSPITALS. 

Burdett.     Cottage  Hospitals.  4.50 

Pay  Hospitals.      -  2.25 

Domville.     Hospital  Nursing.    .75 

HYGIENE. 
Bible  Hygiene.       -       -         i.oo 
Frankland.     Water  Analysis,  i.oo 
Fox.     Water,  Air,  Food.  4.00 

Lincoln.  School  Hygiene.  .50 
Parke's  Hygiene.  7th  Ed.  Net.  4.00 
Wilson's  Handbook  of.  -  2.75 

Domestic.     -        -  i.oo 

KIDNEY  DISEASES. 
Beale.     Renal  and  Urin.  1.75 

Edwards.     How  to  Live  with 

•50 
3.00 
2-75 
3-5° 


1.50 
3.00 


Blight's  Disease 
Greenhow.    Addison's  Dis, 
Ralfe.     Dis.  of  Kidney,  etc 
Tyson.     Bright's  Disease. 

LIVER. 
Habershon.     Diseases  of. 
Harley.     Diseases  of 

LUNGS  AND  CHEST. 

See  Phy.  Diagnosis  and  Throat. 

Williams.     Consumption.        5.00 

MARRIAGE. 
Ryan.     Philosophy  of     -  i.oo 

MATERIA  MEDICA. 

Biddle.     loth  Ed.    -        -  4.00 

Charteris.     Manual  of  -         

Gorgas.     Dental.     2d  Ed.  3.00 

Merrell's  Digest.             -  4.00 

Phillips.     Vegetable.       -  7.50 
Potter's  Compend  of.  4th  Ed.  i.oo 

Handbook  of          -  3.00 

Roberts'  Compend  of.     -  2.00 


CLASSIFIED  LIST  OF  P.  BLAKISTON,  SON  &-  CO.'S  PUBLICA  TIONS. 


MEDICAL  JURISPRUDENCE. 
Abercrombie's  Handbook,  2.50 
Reese's  Text-book  of.  3.00;  Sh.  3.50 
Woodman  and  Tidy's  Treat- 
ise, including  Toxicology.  7.50 
MICROSCOPE. 
Beale.     How  to  Work  with.     7.50 

In  Medicine.         -  7.50 

Carpenter.  The  Microscope.  5.50 
Lee,     Vade  Mecum  of.    -  3.00 

MacDonald.     Examination  of 

Water  by.        ...  2.75 

Martin.  Mounting.  -  $'i-lS 
Wythe.     The  Microscopist.     3.00 

MISCELLANEOUS. 
Allen.     The  Soft  Palate.  .50 

Beale.     Life  Theories,  etc.         2.00 

Slight  Ailments.  1.25 

Black.  Micro-Organisms.  i-5o 
Cobbold.     Parasites,  etc.  5.00 

Edwards.     Malaria.       -  .50 

Vaccination.  -  .50 

Gross.     Life  of  Hunter.  1.25 

Haddon.  Embryology.  -  6.00 
Hare.    Tobacco.  Paper,  .50 

Henry.     Anaemia.   -        -  .75 

Hodge.  Foeticide.  -  Paper,  .30 
Holden.  The  Sphygmograph.  2.00 
Kane.     Opium  Habit.      -  1.25 

MacMunn.  The  Spectroscope  3.00 
Murrell.  Massage.  2d  Ed.  1.23 
Smythe.  Med'l  Heresies.  1.25 
Sutton.    Ligaments.         -  1.25 

Wickes.  Sepulture.         -  1.50 

NERVOUS  DISEASES. 
Buzzard.     Ner.  Affections.      5.00 
Flower.   Atlas  of  Nerves.         3.50 
Gowers.    Manual  of.  In  i  vol. 

Dis.  of  Spinal  Cord.      

Diseases  of  Brain.  2.00 

Epilepsy.      -        -  

Page.     Injuries  of  Spine.  3.50 

Radcliffe.  Epilepsy,  Pain,  etc.  1.25 
■Wilks.     Nervous  Diseases.      6.00 

NURSING. 

Brush,  Nursing  of  the  Insane.  

CuUingworth.    Manual  of.      i.oo 

— Monthly   Nursing.  .50 

Domville's  Manual.         -  .75 

Hood.  Lectures  to  Nurses,  i.oo 
Liickes.  Hospital  Sisters.  i.oo 
Temperature  Charts.    -  .50 

OBSTETRICS. 
Bar.     Antiseptic  Obstet.  1.75 

Barnes.  Obstetric  Operations.  3.75 
Cazeaux  and  Tarnier.     New 

Ed.     Colored  Plates.     -         11.00 
Galabin's  Manual  of.       -  3.00 

Glisan's  Text-book.  2d  Ed.  4.00 
Landis.     Compend.         -  i.oo 

Meadows.     Manual.       -  2.00 

Rigby  and  Meadow's.      -  .50 

Schultze.  Diagrams.  -  25.00 
Tyler  Smith's  Treatise.  4.00 

Swayne's  Aphorisms      -  1.25 

OSTEOLOGY. 

Holden's  Text-book.      -  

PATHOLOGY  &  HISTOLOGY. 
Aitken.  The  Ptomaines,  etc.  i.oo 
2.00 
1-75 
2.00 
7.00 
2.00 
4.50 
I.oo 
4.00 
6.00 


Bowlby,  Surgical  Path. 
Gibbes.  Practical. 
Gilliam.  Essentials  of.  - 
Paget's  Surgical  Path.  - 
Rindfleisch.  General. 
Sutton.  General  Path.  - 
Virchow.     Post-mortems. 

Cell.  Pathology.  - 

Wilkes  and  Moxon.    - 

PHARMACY. 
Beasley's  Druggists'  Rec'ts.    2.25 

Formulary.     -        -  2.25 

FlUckiger.  Cinchona  Barks.  1.50 
Kirby.  Pharm.  of  Remedies.  2.25 
Mackenzie.  Phar.  of  Throat.  1.25 
Merrell's  Digest.     -        -  4.00 


Piesse.     Perfumery.        -  5.50 

Proctor.  Practical  Pharm.  4.50 
Roberts.     Compend  of.  2.00 

Stewart's  Compend.  2d  Ed.  i.oo 
Tuson.     Veterinary  Pharm.     2.50 

PHYSICAL  DIAGNOSIS. 
Bruen's  Handbook.     2d  Ed.     1.50 

PHYSIOLOGY. 
Beale's  Bioplasm.    -        -  2.25 

Brubaker's  Compend.     -  i.oo 

Kirkes'   nth   Ed.     (Author's 

Ed.)  Cloth,  4.00;   Sheep,  5.00 

Landois'  Text-book.  2d  Ed.  6.50 
Sanderson's  Laboratory  B'k.  5.00 
Tyson's  Cell  Doctrine.    -  2.00 

Yeo's   Manual.    2d  Ed.    CI.,  3.00; 
Sheep,  3.50 
POISONS. 
Aitken.    The  Ptomaines,  etc.    1.00 
Black.     Formation  of.      -  i  50 

Reese.     Toxicology.        -  4.00 

Tanner.     Memoranda  of.  .75 

PRACTICE. 
Aitken.     2  Vols.     New  Ed.     12.00 
Beale.     Slight  Ailments.  1.25 

Charteris.  Handbook  of.  1.25 
Fagge's  Practice.  2  Vols.  10.00 
Fenwick's  Outlines  of.    -  1.25 

Hughes.  Compend  of.  2  Pts.  2.00 
Roberts.  Text-book.  5th  Ed.  5.00 
Tanner's  Index  of  Diseases.  3.00 
Warner's  Case  Taking.  1.7s 

PRESCRIPTION  BOOKS. 
Beasley's  3000  Prescriptions.   2.25 

Receipt  Book.        -  2.25 

Formulary.     -         -  2.25 

Pereira's  Pocket-book.  i.oo 

■Wythe's  Dose  and  Symptom 

Book.     17th  Ed.      Just  out.  i.oo 
RECTUM  AND  ANUS. 
Allingham.    Diseases  of.  1.25 

SKIN  AND  HAIR. 
Anderson's  Text-Book,  4.50 

Bulkley,    The  Skin.        -  .50 

Cobbold.     Parasites.        -  5.00 

Van   Harlingen.      Diagnosis 

and  Treatment  of  Skin  Dis.   1.75 
Wilson.     Skin  and  Hair.  i.oo 

STIMULANTS  &  NARCOTICS. 
Anstie.     On.    -        -        -  3.00 

Hare,  Tobacco.  Paper,  .30 

Kane.    Opium  Habit,  etc.  1.25 

Kerr.     Inebriety.      -        -         

Lizars.     On  Tobacco.     - 
Miller.      On  Alcohol 
Parrish.     Inebriety. 

SURGERY. 
Butlin.      Surg,   of   Malignant 

Diseases.         .        -        -  4.00 

Gamgee.     Wounds  and  Frac- 
tures.      -        -        .        -  3.50 
Heath's  Operative.          -        12.00 


•  50 

■50 

1.25 


Minor.    8th  Ed. 
Diseases  of  Jaws. 


Horwitz.   Compend.   3d  Ed.   i.oo 

Jacobson.     Operative  Surg.     

Porter's    Surgeon's    Pocket- 
book.       -        •        -        .  2.25 
Pye.     Surgical  Handicraft.        5.00 
Roberts.     Surgical  Delusions.    .50 

(A.  S.)   Club-Foot.  .50 

Smith.  Abdominal  Surg.  5.00 
Swain.  Surg.  Emergencies.  1.50 
■Walsham.  Practical  Surg.  3  00 
Watson's  Amputations.  5.50 

TECHNOLOGICAL  BOOKS. 
See  also  Chemistry . 
Cameron.     Oils  &  Varnishes.  2.50 
Gardner.     Brewing,  etc. 
Gardner.    Acetic  Acid,  etc. 

Bleaching  &  Dyeing. 

Overman.     Mineralogy. 


Piesse.     Perfumery,  etc. 
Piggott.     On  Copper. 
Thompson.     Physics. 


1-75 
1-75 
1-75 
I.oo 

5-5° 
I.oo 


THERAPEUTICS. 
Biddle.     loth  Ed.    -        -  4.00 

Cohen.     Inhalations.        -  1.25 

Field.  Cathartics  and  Emetics.  1.75 
Headland.  Action  of  Med.  3.00 
Kirby.  Selected  Remedies.  2.25 
Mays.     Therap.  Forces.  1.25 

Ott.  Action  of  Medicines.  2.00 
Phillips.     Vegetable.       -  7.50 

Potter's  Compend.  -  i.oo 

,  Handbook  of.  3.00;  Sh.  3.50 

■Waring's  Practical.        -  ^.00 

THROAT  AND  NOSE. 
Cohen,     Throat  and  Voice. 

Inhalations. 

Greenhow.     Bronchitis. 


•50 
1-25 
1-25 
I.oo 
1.25 
3.00 


2.00 
1-75 
2.00 
■50 
•75 
I.oo 
2-75 


Holmes.     Laryngoscope 

James.     Sore  Throat. 

Journal  of  Laryngology 

Mackenzie.  Throat  and  Nose. 
New  Ed.  Complete  in  one 
vol.     New  lUus.,  etc.       -        — 

The  CEsophagus,  Naso- 
pharynx, etc.         -         3 

Larynx.         -        -  i 

Pharmacopoeia.    - 

Potter.     Stammering,  etc. 
Woakes.  Post-Nasal  Catarrh.  1.50 

Nasal  Polypus,  etc.  1.25 

Deafness,  Giddiness,  etc. 

TRANSACTIONS  AND 

REPORTS. 

Penna.  Hospital  Reports.      1.25 

Power  and  Holmes'  Reports.   1.25 

Trans.  College  of  Physicians.  3.50 

Amer.  Surg.  Assoc.        4.00 

TUMORS  AND  CANCER. 
Hodge.     Note-book  for.  .50 

Thompson.     Of  the  Bladder.  1.75 
Wells.     Abdominal.        -  1.50 

URINE  &  URINARY  ORGANS. 
Acton.     Repro.  Organs. 
Beale.     Urin.  &  Renal  Dis. 

Urin.  Deposits.    Plates 

Holland.     The  Urine.     - 
Legg.     On  Urine.    - 
Marshall  and  Smith.  Urine. 
Ralfe.     Kidney  and  Uri.  Org. 
Thompson.  Urinary  Organs.  1.25 

Surg,  of  Urin.  Organs.    1.25 

Calculous  Dis.       -  i.oo 

Lithotomy.     -        -  3.50 

Prostate.      6th  Ed.  2.00 

Tyson.  Exam,  of  Urine.  1.50 
Van   Niiys.    Urine  Analysis.    

VENEREAL  DISEASES. 
Cooper.     Syphilis.  -        -  3.50 

Durkee.     Gonorrhoea.     -  3.50 

Hill  and  Cooper's  Manual,  i.oo 
Lewin.     Syphilis.  -        -  1.25 

VETERINARY  PRACTICE. 
Tuson's  Vet.  Pharmacopoeia.  2.50 

VISITING  LISTS. 
Lindsay    and     Blakiston's 

Regular  Edition.  i.oo  to  3.00 

Perpetual  Edition.  1.25 

WATER. 
Fox.    Water,  Air,  Food. 
Frankland.    Analysis  of. 
MacDonald.        "         " 

WOMEN,  DISEASES  OF. 

Byford's  Text-book.  4th  Ed.  

•  Uterus.  -        -        -  1.25 

Dillnberger.  and  Children.  1.50 
Doran.  Gynsec.  Operations.  4.50 
Duncan.     Sterility.  -  2.00 

Galabin.     Diseases  of.     -  3.00 

Savage.     Pelvic  Organs.  12.00 

Scanzoni.  Sexual  Organs  of.  4.00 
Tilt.     Change  of  Life.      -  1.25 

Winckel,  by  Parvin.    Manual 
of   lllus.  Clo.,3.00;  Sh.  3.50 


4.00 
I.oo 
2-75 


FAGGE'S  PRACTICE. 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICINE.  By  C.  HiLTON 
Fagge,  M.D.,  F.R.C.P.,  F.R.M.C.S.,  Examiner  in  Medicine,  University  of  Lon- 
don; Physician  to,  and  Lecturer  on  Pathology  in,  Guy's  Hospital;  Senior 
Physician  to  Evelina  Hospital  for  Sick  Children,  etc.  Arranged  for  the  press 
by  P.  H.  Pye-Smith,  m.d.,  Lect.  on  Medicine  in  Guy's  Hospital,  Including 
a  section  on  Cutaneous  Affections,  by  the  Editor ;  chapter  on  Cardiac  Dis- 
eases, by  Samuel  Wilkes,  m.d.,  f.r.s.,  with  a  very  complete  Index  of 
Authors  and  one  of  Subjects,  by  Robert  Edmund  Carrington. 

Two  Volumes.      Royal  Octavo.      1900  Pages. 

SOLD  BY  SUBSCRIPTION  ONLY. 

Handsome  Cloth,  $10,00.  Full  Leather,  Raised  Boards,  $12.00. 

One-Half  Russia,  $14.00.          One-Half  Morocco,  $14.00. 

This  work  on  the  Practice  of  Medicine  is  based  on  laborious  researches  into 
the  pathological  and  clinical  records  of  Guy's  Hospital,  London,  during  the 
twenty  years  in  which  the  author  held  office  there  as  Medical  Registrar,  as  Patholo- 
gist, and  as  Physician.  Familiar,  beyond  most,  if  not  all,  of  his  contemporaries, 
with  modern  medical  literature,  a  diligent  reader  of  French  and  German  periodi- 
cals. Dr.  Fagge,  with  his  remarkably  retentive  memory  and  methodical  habits, 
was  able  to  bring  to  his  work  of  collection  and  criticism  almost  unequaled 
opportunities  of  extensive  experience  in  the  wards  and  dead  house.  The  result 
is  that  which  will  probably  be  admitted  to  be  a  fuller,  more  original,  and  more 
elaborate  text-book  on  medicine  than  has  yet  appeared.  It  is  the  first  of  import- 
ance emanating  from  Guy's  Hospital,  and  the  only  two-volume  work  on  the 
Practice  of  Medicine  that  has  been  issued  for  a  number  of  years.  Several  subjects, 
such  as  Syphilis,  that  are  usually  omitted  or  but  slightly  spoken  of  in  a  general 
work  of  this  character,  receive  full  attention.  The  section  on  Nervous  Diseases  is 
very  exhaustive,  and  that  on  Diseases  of  the  Respiratory  Organs  and  Larynx  are 
equally  full.  The  author  has  adopted  a  very  simple  and  practical  plan  in  the 
treatment  of  Lung  Diseases,  and  Phthisis  receives  full  consideration.  The  chapter 
on  Cardiac  Diseases,  by  Dr.  Sam'I  Wilkes,  is  most  carefully  written,  and  the 
parts  devoted  to  Cutaneous  Affections,  by  Dr.  Pye-Smith,  are  excellent. 

PRESS  NOTICES. 

"  Those  who  have  read  Guy's  Hospital  Reports  for  the  past  twenty  years  and  the  many  articles  in  the 
different  English  journals  from  the  pen  of  Charles  Hilton  Fagge  will  expect  a  comprehensive,  carefully- 
prepared  and  painstaking  volume.  They  will  not  be  disappointed.  One  cannot  proceed  far  in  the  reading 
of  this  book  before  he  is  impressed  with  certain  features  of  it  which  are  very  remarkable.  Let  him  turn  to 
almost  any  page  at  random,  and  he  is  likely  to  find  reference  made  to  a  dozen  authors ;  the  authors  being, 
perhaps,  of  three  orfour  different  nationalities.  The  author  is  said  to  have  been  very  familiar  with  German, 
French  and  Italian,  which,  with  his  own  English,  would  give  him  four  different  languages  from  which  to 
cull  his  information.  His  memory  must  have  been  marvelous,  and  he  was  an  original  worker  and  thinker. 
*  *  *  We  close  the  first  volume  feeling  that  here  was  a  master.  *  *  *  Will  take  and  hold  the  very 
front  rank  among  works  on  the  practice  of  medicine.  *  *  *  A  general  and  complete  index  to  both  volumes 
adds  great  value  to  its  usefulness.  One  is  gratified  to  find  reference  to  no  fewer  than  thirty  American  authors. 
Certainly  these  two  volumes  make  a  complete  work  on  practice,  whether  as  a  book  of  reference  or  even  as  a 
text-book.  It  is  in  style  worthy  of  a  second  place  only  to  the  classical  work  of  Sir  Thomas  Watson." — Ne-jj 
York  Medical  Journal. 

"  If  the  second  volume  of  this  treatise  fulfills  the  promise  of  excellence  contained  in  the  one  before  us 
the  entire  work  cannot  fail  to  find  favor  with  the  profession  both  here  and  abroad." — I^eiv  Vork  Medical 
Record,  notice  of  Vol.  I. 

"  The  finest  of  all  treatises  on  the  healing  art.  It  should  be  in  every  physician's  library." — Cincinnati 
Lancet  and  Clinic. 

"  A  perusal  of  its  pages  shows  that  it  is  one  of  the  most  scientific  and  philosophical  works  of  its  kind, 
being,  in  truth,  a  mine  of  clinical  and  pathological  facts,  which  are  dealt  with  in  so  masterly  a  manner  that 
we  know  not  which  to  admire  most — the  patient  labor  and  thought  expended  in  bringing  them  to  light,  the 
learning  and  acumen  that  illustrate  them,  or  the  calm  and  judicial  spirit  in  which  they  are  estimated  and 
criticised." — London  Lancet. 

"  The  work  is  an  English  classic.  *  *  *  His  great  treatise  remains  a  monument  more  enduring  than 
fame." — Dublin  Journal  of  Medicine. 

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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  7 

BIBLE  HYGIENE ;  or  Health  Hints.  By  a  physician.  Written  to  impart  in  a 
popular  and  condensed  form  the  elements  of  Hygiene ;  showing  how  varied  and 
important  are  the  Health  Hints  contained  in  the  Bible,  and  to  prove  that  the 
secondary  tendency  of  modern  Philosophy  runs  in  a  parallel  direction  with  the 
primary  light  of  the  Bible.     i2mo.  Cloth,  $i.oo 

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Medica  in  Jefferson  Medical  College,  Philadelphia.  The  Tenth  Edition,  thor- 
oughly revised,  and  in  many  parts  rewritten,  by  his  son,  Clement  Biddle,  m.d.. 
Assistant  Surgeon,  U.  S.  Navy,  and  Henry  Morris,  m.d.,  Demonstrator  of 
Obstetrics  in  Jefferson  Medical  College,  Fellow  of  the  College  of  Physicians,  of 
Philadelphia,  etc.  The  Botanical  portions  have  been  curtailed  or  left  out,  and 
the  other  sections,  on  Therapeutics  and  the  Physiological  action  of  Drugs,  greatly 
enlarged.  Cloth,  ^4.00;  Leather,  ^4.75 

BLACK.  Micro-Organisms.  The  Formation  of  Poisons  by  Micro-Organisms.  A 
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Cloth,  ^1.50 

BLOXAM.  Chemistry,  Inorganic  and  Organic.  With  Experiments.  By 
Charles  L.  Bloxam,  Professor  of  Chemistry  in  King's  College,  London,  and  in 
the  Department  for  Artillery  Studies,  Woolwich.  Sixth  Edition.  Revised.  With 
nearly  300  Engravings.     8vo.  Cloth,  $3.75  ;   Leather,  $4.75 

Laboratory  Teaching,  Progressive  Exercises  in  Practical  Chemistry.  In- 
tended for  use  in  the  Chemical  Laboratory,  by  those  who  are  commencing 
the  study  of  Practical  Chemistry.     4th  Edition.     89  lUus.  Cloth,  $1.75 

BOWLBY.  Surgical  Pathology  and  Morbid  Anatomy.  By  Anthony  A. 
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St.  Bartholomew's  Hospital,  etc.     135  Illustrations.  Cloth,  $2.00 

BOWMAN.  Practical  Chemistry,  including  analysis,  with  about  100  Illustrations. 
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Professor  of  Chemistry,  King's  College,  London.  Cloth,  $2.00 

BEAUNE.  Atlas  of  Topographical  Anatomy.  Thirty-four  Full-page  Plates, 
Photographed  on  Stone,  from  Plane  Sections  of  Frozen  Bodies,  with  many  other 
illustradons.  By  Wilhelm  Braune,  Professor  of  Anatomy  at  Leipzig.  Trans- 
lated and  Edited  by  Edward  Bellamy,  f.r.c.s..  Lecturer  on  Anatomy,  Char- 
ing Cross  Hospital,  London.     4to.  Cloth,  |8.oo;  Half  Morocco,  ^10.00 

BRITBAKEE.  Physiology.  A  Compend  of  Physiology,  specially  adapted  for  the 
use  of  Students  and  Physicians.  By  A.  P.  Brubaker,  m.d.,  Demonstrator  of 
Physiology  at  Jefferson  Medical  College,  Prof,  of  Physiology,  Penn'a  College  of 
Dental  Surgery,  Philadelphia.  Fourth  Edition.  Revised,  Enlarged  and  Illus- 
trated.    "  No.  4,  ?  Quiz-Compend  Series  ?  "     i2mo.  Cloth,  $1.00 

Interleaved  for  the  addition  of  notes,  |;i.25 

BRTIEN.  Physical  Diagnosis.  For  Physicians  and  Students.  By  Edward  T. 
Bruen,  m.d.,  Asst.  Professor  of  Physical  Diagnosis  in  the  University  of  Pennsyl- 
vania.    Illustrated  by  Original  Wood  Engravings.     i2mo.    2d  Ed.    Cloth,  ^1.50 

BRUSH,  Manual  for  Attendants  on  the  Insane.  A  manual  for  the  Instruction  of 
Attendants  and  Nurses  in  Hospitals  for  the  Insane.  By  Edavard  N.  Brush, 
M.D.,  Senior  assistant  Physician,  Department  of  Males,  Pennsylvania  Hospital  for 
Insane,  Philadelphia  ;  Late  Senior  Ass't.  Physician  N.  Y.  State  Lunatic  Asylum, 
Udca.  Including  lectures  on  Anatomy,  Chemistry,  Physiology,  Hygiene,  etc. 
i2mo.     Cloth. 

BTJCKNILL  AND  TTJKE'S  Manual  of  Psychological  Medicine :  containing 
the  Lunacy  Laws,  the  Nosology,  Etiology,  Statistics,  Description,  Diagnosis, 
Pathology  (including  morbid  Histology)  and  Treatment  of  Insanity.  By  John 
Charles  Bucknill,  m.d.,  f.r.s.,  and  Daniel  Hack  Tuke,  m.d.,  f.r.c.p. 
Fourth  Edition,  much  enlarged,  with  twelve  hthographic  and  numerous  other 
illustrations.     8vo.  Cloth,  $8.00 


p.  BLAKISTON,  SON  &-  CO:S 


BITLKLEY.  The  Skin  in  Health,  and  Disease.  By  L.  Duncan  Bulkley,  m.d., 
Attending  Physician  at  the  New  York  Hospital.     Illustrated.  Cloth,  .50 

BITRDETT'S  Pay  Hospitals  and  Paying  Wards  throughout  the  World.  Facts  in 
support  of  a  rearrangement  of  the  system  of  Medical  Relief.     By  Henry  C. 

BURDETT,  M.D.      8v0.  Cloth,  $2.25 

Cottage  Hospitals.  General,  Fever  and  Convalescent;  their  Progress, 
Management  and  Work.  Second  Edition.  Rewritten  and  Enlarged,  with 
Plans  and  Illustrations.     Crown  8vo.  Cloth,  $4.50 

BURNETT.  Hearing,  and  How  to  Keep  It.  By  Chas.  H.  Burnett,  m.d..  Prof, 
of  Diseases  of  the  Ear,  at  the  Philadelphia  Polyclinic.     Illustrated.        Cloth,  .50 

BUTLIN.  Operative  Surgery  of  Malignant  Diseases.  By  Henry  T.  Butlin, 
Asst.  Surg,  to  St.  Bartholomew's  Hospital,  London,  etc.  Cloth,  ^4.00 

BUZZARD.    Clinical  Lectures  on  Diseases  of  the  Nervous  System.    By  Thos. 

Buzzard,  m.d.     Illustrated.     Octavo.  Cloth,  $5.00 

BYFORD.  Diseases  of  Women.  The  Practice  of  Medicine  and  Surgery,  as 
applied  to  the  Diseases  and  Accidents  Incident  to  Women.  By  W.  H.  Byford, 
A.M.,  M.D.,  Professor  of  Gynaecology  in  Rush  Medical  College  and  of  Obstetrics 
in  the  Woman's  Medical  College;  Surgeon  to  the  Woman's  Hospital ;  Ex-Presi- 
dent American  Gynaecological  Society,  etc.,  and  Henry  T.  Byford,  m.d..  Sur- 
geon to  the  Woman's  Hospital  of  Chicago ;  Gynaecologist  to  St.  Luke's  Hos- 
pital ;  President  Chicago  Gynaecological  Society,  etc.  Fourth  Edition.  Revised, 
Rewritten  and  ^Enlarged.  With  306  Illustrations,  over  100  of  which  are  original. 
Octavo.     Over  800  pages.  Cloth,  $5.00  ;  Leather,  $6.00 

On  the  Uterus.     Chronic  Inflammation  and  Displacement.  Cloth,  ^1.25 

CARPENTER.  The  Microscope  and  Its  Revelations.  By  W.  B.  Carpenter, 
m.d.,  f.r.s.  Sixth  Edition.  Revised  and  Enlarged,  with  over  500  Illustrations 
and  Lithographs.  Cloth,  $5.50 

CARTER.  Eyesight,  G-OOd  and  Bad.  A  Treatise  on  the  Exercise  and  Preservation 
of  Vision.  By  Robert  Brudenell  Carter,  f.r.c.s.  Second  Edition,  with  50 
Illustrations,  Test  Types,  etc.     i2mo.  Paper,  .75  ;   Cloth,  $1.25 

CAZEAUX  and  TARNIER'S  Midwifery.  With  Appendix,  by  Munde.  Eighth 
Revised  and  Enlarged  Edition.  With  Colored  Plates  and  numerous  other 
Illustrations.  The  Theory  and  Practice  of  Obstetrics  ;  including  the  Diseases 
of  Pregnancy  and  Parturition,  Obstetrical  Operations,  etc.  By  P,  Cazeaux, 
Member  of  the  Imperial  Academy  of  Medicine,  Adjunct  Professor  in' the  Faculty 
of  Medicine  in  Paris.  Remodeled  and  rearranged,  with  revisions  and  additions, 
by  S.  Tarnier,  m.d.,  Professor  of  Obstetrics  and  Diseases  of  Women  and 
Children  in  the  Faculty  of  Medicine  of  Paris.  Eighth  American,  from  the 
Eighth  French  and  First  Italian  Edition.  Edited  and  Enlarged  by  Robert 
J.  Hess,  m.d..  Physician  to  the  Northern  Dispensary,  Phila.,  etc.,  with  an  Ap- 
pendix by  Paul  F.  Munde,  m.d..  Professor  of  Gynaecology  at  the  New  York 
Polyclinic,  and  at  Dartmouth  College  ;  Vice-President  American  Gynaecological 
Society,  etc.  Illustrated  by  Chromo-Lithographs,  Lithographs,  and  other  Full- 
page  Plates,  seven  of  which  are  beautifully  colored,  and  numerous  Wood  En- 
gravings.    Two  Volumes,  Royal  Square  octavo.     1221  pages. 

Cloth,  $11.00;  Full  Leather,  $13.00 ;  Half  Russia  or  Half  Morocco,  $15.00. 
Sold  only  by  Sicb  script  ion.     Full  Circulars  aftd  Information  upofi  Application. 

CHARTERIS.  The  Practice  of  Medicine.  A  Handbook.  By  M.  Charteris, 
M.D.,  Member  of  Hospital  Staff  and  Professor  in  University  of  Glasgow.  With 
Microscopic  and  other  Illustrations.  Cloth,  $1.25 

Materia  Medica  and  Therapeutics.    A  Manual  for  Students.         In  Press. 

CHAVASSE.    The  Mental  Culture  and  Training  of  Children.    By  Pye  Henry 

Chavasse.     i2mo.  Cloth,  $1.00 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  9 

CHURCHILL.  Face  and  Foot  Deformities.  By  Fred.  Churchill,  m.d., 
Ass't  Surgeon  to  the  Victoria  Hospital  for  Sick  Children,  London.  Six  Plain 
and  Two  Colored  Lithographs.     8vo.  Cloth,  $3.50 

CLEVELAND'S  Pocket  Dictionary.  A  Pronouncing  Medical  Lexicon,  containing 
correct  Pronunciation  and  Definition  of  terms  used  in  medicine  and  the  col- 
lateral sciences,  abbreviations  used  in  prescriptions,  list  of  poisons,  their  anti- 
dotes, etc.  By  C.  H.  Cleveland,  m.d.  Thirty-second  Edition.  Very  small 
pocket  size.  Cloth,  .75;  Tucks  with  Pocket,  ^i.oo 

COBBOLD.  A  Treatise  on  the  Entozoa  of  Man  and  Animals,  including  some 
account  of  the  Ectozoa.  By  T.  Spencer  Cobbold,  m.d.,  f.r.s.  With  85  Illus- 
trations.    8vo.  Cloth,  15.00 

COHEN  on  Inhalation,  its  Therapeutics  and  Practice,  including  a  Description  of 
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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  17 

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100         "           "                         "            "                     "         «'         <<                   _  2.00 

<<  1         f  Ian.  to  Tune  ]  t,         <<         ,< 

5°                      -2^o\s.      jjulytoDecj                          "         "  .         .  2.50 

((  <<  I        (Jan.  to  June]  ,,         ,,         ,,  ^  ^„ 

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.<  <<  1       f  Jan.  to  Tune  ]      ,,        ,,         ,,         ,,  „  „_, 

5°  2^°1^-    I  July  to  Dec.  I  '        '  3-oo 

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18  ,        P.  BLAKISTON,  SON  &-  CO.'S 

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22  P.  BLAKISTON,  SON  &-  CO:S 


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Holden's  Manual  of  Anatomy. 

FIFTH  EDITION,  REVISED  AND  ENLARGED.    208  ILLUSTRATIONS. 
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DIAGRAM    OF   AXILLA 
(From.  Holden' s  Anatomy  ) 


1.  Axillary  Artery. 

2.  Brachial  Artery. 

3.  Thoracica  Humeraria  Artery. 

4.  Superior  Thoracic  Artery. 

5.  Subscapular  Artery. 

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CEUTICAL  STUDENTS  AND  PRACTITIONERS. 


A  Text-Book  of  Medical  Chemistry. 

BY  E.  H.  BARTLEY,  M.D., 

Associate  Professor  of  Chemistry  at  the  Long  Island  College  Hospital ;  President  of  the  American  Society  of 
Public  Analysts  ;  Chief  Chemist,  Board  of  Health,  of  Brooklyn,  N.  Y.,  etc. 

Illustrated  12mo.    Cloth,  $2.50. 

This  book,  writteh  especially  for  students  and  physicians,  aims  to  be  a  text-book 
for  the  one  and  a  work  of  reference  for  the  other.  It  is  practical  and  concise,  dealing 
only  with  those  parts  of  chemistry  pertaining  to  medicine  ;  no  time  being  wasted  in 
long  descriptions  of  substances  and  theories  of  interest  only  to  the  advanced  chemi- 
cal student. 

PART  I — Treats  of  Light,  Heat  and  Electricity,  which  are  described  at  some  length,  and  explanations  made 
and  applied  to  common  phenomena.  In  the  subject  of  light,  only  so  much  is  given  as  will  explain  the  theory 
and  use  of  the  spectroscope.  In  electricity,  the  principal  aim  has  been  to  give  such  information  as  is  needed 
for  the  proper  understanding,  working  and  care  of  the  medical  battery. 

PART  II — Theoretical  Chemistry.  Only  such  portions  of  the  well  established  principles  of  modern  chemistry 
as  are  necessary  to  an  understanding  of  the  subject  are  given.  It  has  been  deemed  best  to  present  all  these 
elementary  parts  first,  that  the  student  may  be  better  able  to  study  any  set  of  isolated  facts.  These  theories 
are  presented  in  a  concise,  clear  way,  in  a  logical  order  and  in  a  manner  which  the  author  has  found  specially 
successful  in  an  experience  of  over  twelve  years  of  teaching. 

PART  III — Treats  of  the  natural  history  of  the  elements,  of  their  principal  compounds,  with  their  physiological 
action  and  toxicology. 

PART  IV— Organic  bodies  commonly  used  in  medicine  and  pharmacy.  The  principal  organic  substances 
derived  from  animal  life  are  given  a  place.  In  the  appendix  will  be  found  analyses  of  the  principal  secretions 
and  tissues,  tables  of  solubilities  and  of  specific  gravities,  the  metric  system,  and  other  useful  information. 

Applied  Medical   Chemistry. 

Containing  a  description  of  the  apparatus  and  methods  employed  in  the  practice 
of  Medical  Chemistry,  the  Chemist^  of  Poisons,  Physiological  and  Pathological 
Analysis,  Urinary  and  Fecal  Analysis,  Sanitary  Chemistry  and  the  Examination  of 
Medicinal  Agents,  Foods,  etc. 

BY  LAWRENCE  WOLFF,  M.D., 

Demonstrator  of  Chemistry  in  the  Jefferson  Medical  College ;  Member  of  the  Philadelphia  College  of  Pharmacy 
and  of  the  Chemical  Section  of  the  Franklin  Institute,  etc. 

Octavo,  Clotli,  $1  50. 
*^^*The  object  oi  the  author  of  this  book  is  to  furnish  the  practitioner  and  student 
a  reliable  and  simple  guide  for  making  analyses  and  examinations  of  the  various 
medicinal  agents,  human  excretions,  secretions,  etc.,  without  elaborate  apparatus  or 
expensive  processes. 

Practical  and  Analytical  Chemistry. 

Being  a  complete  course  in  Chemical  Analysis,  for  pharmaceutical  and  medical 
students. 

BY  HENRY  TRIMBLE,  Ph.G., 
Professor  of  Analytical  Chemistry  in  the  Philadelphia  College  of  Pharmacy. 

Second  Edition.    Illustrated.    8vo.    Cloth,  $1.50. 

SUMMARY  OF  CONTENTS.  Part  I.  Practical— Preparation  and  Properties  of  Gases,  Preparation  of  Salts, 
etc.  Part  II.  Section  I — Bases.  Group  I — Potassium,  Sodium,  Lithium,  Ammonium.  Group  II — Barium, 
Strontium,  Calcium,  Magnesium.  Group  III — Manganese,  Zinc,  Cobalt,  Nickel.  Group  IV — Iron,  Cerium, 
Chromium,  Aluminium.  Groujp  V — Arsenic,  Antimony,  Tin,  Gold,  Platinum.  Group  VI — Mercury  (ic), 
Bismuth,  Copper,  Cadmium.  Group  VII — Silver,  Mercury  (ous),  Lead.  Section  II — Acids.  Section  III — 
Detection  of  Bases  and  Acids.  Section  IV — Some  of  the  Reactions  and  Tests  of  Purity  of  the  more  import- 
ant Organic  Compounds.  Part  III.  Quantitative  Chemical  Analysis.  Section  I — Gravimetric  Estimation. 
Section  II — Volumetric  Estimation.     There  are  also  a  number  of  useful  Tables. 

LBPPMANN'S  ORGANIC  AND  MEDICAL  CHEMISTRY.  Including 
Urine  Analysis  and  the  Analysis  of  Water  and  Food.  By  Henry  Leffmann, 
M.D.,  Demonstrator  of  Chemistry  at  Jefferson  Medical  College,  Philadelphia. 
i2mo.  Cloth,  $i.oo;  Interleaved  for  the  addition  of  Notes,  ;^i.25 

P.  BLAKISTON,  SON  &  CO.,  ioi2  Walnut  St.,  Philadelphia. 


Practical  Handbooks 

FOR  THE  PHYSICIAN  and  MEDICAL  STUDENT. 


VAN  HARL.INGEN  ON  SKIN  DISEASES.  A  Handbook  of  the  Diag- 
nosis and  Treatment  of  Skin  Diseases.  Py  Arthur  Van  Harlingen,  m.d., 
Professor  of  Diseases  of  the  Skin  in  the  Philadelphia  Polyclinic ;  Consulting 
Physician  to  the  Philadelphia  Dispensary  for  Skin  Diseases,  and  Dermatologist 
to  the  Howard  Hospital.  With  colored  plates  representing  the  appearance  of 
various  lesions.     i2mo.  Cloth,  ^^1.75 

*^*This  is  a  complete  epitome  of  skin  diseases,  arranged  in  alphabetical  order, 
giving  the  diagnosis  and  treatment  in  a  concise,  practical  way.  Many  prescriptions 
are  given  that  have  never  been  published  in  any  text-book,  and  an  article  incorporated 
on  Diet.  The  plates  do  not  represent  one  or  two  cases,  but  are  composed  of  a  num- 
ber of  figures,  accurately  colored,  showing  the  appearance  of  various  lesions,  and 
will  be  found  to  give  great  aid  in  diagnosing. 

'"  This  new  handbook  is  essentially  a  small  encyclopEedia.  «  »  *  Contains  a  very  complete  summary  of  the 
present  state  of  Dermatology.  *  *  *  We  heartily  commend  it  for  its  brevity,  clearness  and  evidently  careful 
preparation." — Philadelphia  Medical  Times. 

"  The  author  shows  a  proper  appreciation  of  the  wants  of  the  general  practitioner." — /^ew  York  Medical 
Record. 

"  It  is  concisely  and  intelligently  written,  and  contains  many  of  the  best  formulas  in  use  for  the  various  forms 
of  Skin  Disease." — New  York  Medical  Times. 

"  This  is  an  excellent  little  book,  in  which,  for  ease  of  reference,  the  more  common  diseases  of  the  skin  are 
arr^ged  in  alphabetical  order,  while  many  good  prescriptions  are  given,  together  with  clear  and  sensible  direc- 
tions as  to  their  proper  application." — Boston  Medical  and  Surgical  yournal. 

"  It  is  just  the  kind  of  book  that  the  general  practitioner  will  find  most  convenient  for  reference,  and  we  feel 
confident  that  it  will  be  appreciated." — Southern  Practitioner. 

BINDFLEISOH'S  PATHOLOGY.  The  Elements  of  Pathology.  By  Prof. 
Edward  Rindfleisch,  University  of  Wiirzburg.  Authorized  translation  from 
the  first  German  edition,  by  Wm.  H.  Mercur,  m.d.  (Univ.  of  Pa.)  Revised  by 
James  Tyson,  m.d..  Professor  of  Pathology  and  Morbid  Anatomy  in  the  Univer7 
sity  of  Pennsylvania.     l2mo.  Cloth,  $'Z.oo 

Prof.  Tyson,  in  his  Preface  to  the  American  edition,  says  : — "A  high  appreciation  of  Prof.  Rindfleisch's 
work  on  Pathological  Histology,  caused  me  to  make  careful  examination  of  these  '  Elements '  immediately  after 
their  publication  in  the  original.  From  such  an  examination  I  became  satisfied  that  the  book  would  fill  a  niche 
in  the  wants  of  the  student,  as  well  as  of  others  who  may  desire  to  familiarize  themselves  with  general  patho- 
logical processes,  viewed  from  the  mpst  modem  standpoint." 

BRUBN'S  PHYSICAL  DIAGNOSIS.  Second  Edition.  A  Pocket-book 
of  Physical  Diagnosis  of  the  Heart  and  Lungs ;  for  the  Student  and  Physician. 
By  Edward  T.  Bruen,  Demonstrator  of  Clinical  Medicine  in  the  University  of 
Pennsylvania ;  Lecturer  on  Pathology  in  the  Women's  Medical  College  of  Phila- 
delphia; 2d  Edition,  revised,  with  new  original  illustrations.     i2mo.    Cloth,  |S  1.50 

"  We  consider  the  description  of  the  manner  and  rules  governing  the  art  of  perctission  well  given.  The  sub- 
ject is  always  a  difficult  one  for  beginners,  and  requires  to  be  well  handled  in  order  to  be  properly  understood." 
■ — American  jfournal  of  Medical  Sciences. 

WOAKES  ON  CATARRH  AND  DISEASES  OP  THE  NOSE  CAUS- 
ING DEAFNESS.  By  Edward  Woakes,  m.d.,  Senior  Aural  Surgeon  to 
the  London  Hospital  for  Diseases  of  the  Throat  and  Chest.  29  Illustrations. 
i2mo.  Cloth,  $1.50 

"  Out  of  the  large  number  of  special  works  On  catarrh,  there  is  none  for  which  we  have  such  an  unqualified 
good  opinion.  *  *  *  The  subject  is  clearly  presented.  •  «  •  The  line  of  treatment  suggested  is  rational." 
— North  Carolina  Medical  yournal. 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


THE  PRACTICAL  SERIES. 

TWO  NEW  VOLUMES  JUST  READY. 

***  The  volumes  of  this  series,  written  by  well-known  physicians  and  surgeons  of 
large  private  and  hospital  experience,  recognized  authorities  on  the  subjects  of  which 
they  treat,  will  embrace  the  various  branches  of  medicine  and  surgery.  They  are  of 
a  thoroughly  practical  character,  calculated  to  meet  the  requirements  of  the  practi- 
tioner, and  will  present  the  most  recent  methods  and  information  in  a  compact  shape 
and  at  a  low  price. 

Bound  TJniformly,  in  a  Handsome  and  Distinctive  Cloth  Binding. 
TREATMENT  OF  DISEASE  IN  CHILDREN.  Including  the  Outlines 
of  Diagnosis  and  the  Chief  Pathological  Differences  between  Children  and 
Adults.  By  Angel  Money,  m.  d.,  m.r.c.p.,  Assistant  Physician  to  the  Hospital 
for  Sick  Children,  Great  Ormond  St.,  and  to  the  Victoria  Park  Chest  Hospital, 
London.     i2mo.     560  pages.  Cloth,  ^3.00 

ON  FEVERS.  A  Practical  Treatise  on  Fevers,  Their  History,  Etiology,  Diag- 
nosis, Prognosis  and  Treatment.  By  Alexander  Collie,  m.d.,  m.r.c.p.,  Lond. 
Medical  Officer  Homerton  Fever  Hospital,  and  of  the  London  Fever  Hospital. 
With  Colored  Plates.  Cloth,  $2.50 

"This  volume,  which  forms  one  of  the  '  Practical  Series'  of  Medical  and  Surgical  Manuals,  deserves  attention 
from  the  fact  that  its  author  has  been  so  long  devoted  to  the  subjects  of  which  it  treats.  He  is,  therefore,  in 
position  to  speak  with  authority  as  well  as  with  complete  freedom  and  independence.  *  *  *  *  The  strongest 
parts  of  the  work  are  those  which  deal  with  diagnosis  and  treatment,  for  here  Dr.  Collie  is  thoroughly  at  home, 
and  succeeds  in  imparting  to  the  work  its  'practical  character,  for  which  it  will  be  highly  valued.' " — London 
Lancet,  April  23d,  1887. 

HANDBOOK  OF  DISEASES  OP  THE  EAR.  By  Urban  Pritchard, 
M.D.,  F.R.C.S.,  Professor  of  Aural  Surgery,  King's  College,  London,  Aural  Sur- 
geon to  King's  College  Hospital,  Senior  Surgeon  to  the  Royal  Ear  Hospital,  etc. 
i2mo.  Cloth,  #1.50 

"  Exactly  what  is  wanted  at  the  present  moment,  we  can  recommend  every  practitioner  to  have  a  copy." — 
.London  Practitioner. 

"A  first-rate  little  book.  *  *  *  The  man  who  wants  a  short,  reliable  book  will  buy  Dr.  Pritchard's." — 
New  Orleans  Medical  and  Surgical  Journal. 

"Written  from  an  eminently  practical  standpoint.  *  *  *  *  Commended  for  its  simplicity  and  directness." 
—Neiv  York  Medical  Journal. 

"Belongs  to  a  class  that  is  very  useful  to  the  general  practitioner." — Maryland  Medical  Journal. 

DISEASES  OF  THE  KIDNEYS,  AND  URINARY  DERANGE- 
MENTS. By  C.  H.  Ralfe,  m.a.,  m.d.,  f.r.c.p..  Assistant  Physician  to  the 
London  Hospital ;  late  Senior  Physician  to  the  Seamen's  Hospital,  Greenwich. 
i2mo.     With  Illustrations.     572  pages.  Cloth,  I2.75 

"  It  is  with  keen  pleasure  that  we  recommend  this  really  meritorious  book  to  our  readers." — New  York  Medical 
Journal. 

"A  clear,  concise  and  systematic  account  of  urinary  pathology  and  therapeutics.  *  *  *  *  fhe  student 
will  find  in  these  pages  all  necessary  instruction  imparted  in  a  candid  and  not  dogmatic  manner,  and  the  practi- 
tioner will  find  a  ready  and  convenient  reference  book." — Boston  Medical  and  Surgical  Journal. 

BODILY  DEFORMITIES  AND  THEIR  TREATMENT.  A  Handbook 
of  Practical  Orthopgedics.  By  H.  A.  Reeves,  f.r.c.s..  Senior  Assistant  Surgeon 
and  Teacher  of  Practical  Surgery  at  the  London  Hospital ;  Surgeon  to  the  Royal 
Orthopedic  Hospital,  etc.     i2mo.     228  Illustrations.     460  pages.        Cloth,  ^2.25 

"  From  what  we  have  already  said,  it  will  be  seen  that  Mr.  Reeves  has  given  us  a  trustworthy  guide  for  the 
treatment  of  a  very  extended  class  of  cases.  *  *  *  *  If  the  other  volumes  of  the  Practical  Series  are  as  good 
as  this,  we  shall  be  agreeably  d\?.?c^\iamX.e:d.." —American  Journal  oj  Medical  Sciences,  April,  JS83. 

"  The  utility  of  the  work  now  before  us  cannot  be  better  recommended  to  the  appreciation  of  the  professional 
reading  public  than  by  recalling  that  it  is  the  first  of  its  kind,  dealing  with  orthopaedics  from  a  modern  stand- 
point.''— Hospital  Gazette  and  Students'  Jourtial. 

DENTAL  SURGERY  FOR  GENERAL  PRACTITIONERS  AND 
STUDENTS  IN  MEDICINE.  By  Ashley  W.  Barrett,  m.d.,  m.r.c.s., 
Eng.,  Surgeon-Dentist  to,  and  Lecturer  on  Dental  Surgery  and  Pathology  in  the 
Medical  School  of,  London  Hospital.     i2mo.     Illustrated.  Cloth,  ^i.oo 

"Replete  with  an  abundance  of  practical  information  of  unquestionable  utility." — Hospital  Gazette  and 
Students'  Journal. 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


PERIODICALS  PUBLISHED  BY  P.  BLAKISTON,  SON  &  CO. 

THE   POLYCLINIC.     Vol.  V. 

A  Monthly  Journal  of  Medicine  and  Surgery.  Doubled  in  Size  Without  Increase  of  Price. 

$1.00  PER  ANNUM.     SAMPLE  COPIES  FREE. 

EDITORIAL    STAFF. 
EDITOR-IN-CHIEF,  HENRY  LEFFMANN,  M.D. 

Diseases  of  the  Throat  and  Chest.  J.  Solis-Cohen,  m.d.,  Professor  of  Dis- 
eases of  the  Throat  and  Chest  in  the  Philadelphia  Polyclinic. 

General  Surgery,  Orthopaedics,  Operative  and  Clinical  Surg-ery.  Johx 
B.  Roberts,  m.d.,  Surg,  to  St.  Mary's  Hosp. ;  Chas.  B.  Nancrede,  m.d.,  Surg, 
to  the  Episcopal  and  to  St.  Christopher's  Hosps. ;  Lewis  W.  Steinbach,  m.d., 
Wm.  Barton  Hopkins,  m.d.,  Asst.  Demonstrator  of  Surgery,  Univ.  of  Penna., 
A.  B.  Hirsh,  m.d. 

Diseases  of  the  Bar.  Charles  H.  Burnett,  m.d..  Aural  Surgeon  to  the  Presby- 
terian Hospital. 

Diseases  of  the  Mind  and  Nervous  System.  Charles  K.  Mills,  m.d..  Lec- 
turer on  Mental  Diseases,  University  of  Pennsylvania ;  Consulting  Physician 
Insane  Department,  Philadelphia  Hospital. 

Diseases  of  the  Skin.  Arthur  Van  Harlingen,  m.d..  Consulting  Physician 
Dispensary  for  Skin  Diseases  ;  Physician  to  Howard  Hosp.  Dermatological  Dept. 

Diseases  of  the  Eye.  George  C.  Harland,  m.d..  Surgeon  to  Wills  Eye  Hospi- 
tal and  to  the  Eye  and  Ear  Dept,  Penna.  Hosp.;  Howard  F.  Hansell,  m.d.. 
Physician  to  Southeastern  Hospital  and  Manayunk  Eye  and  Ear  Dispensary. 

Genito -Urinary  and  Venereal  Diseases.  J.  Henry  C.  Simes,  m.d..  Surgeon 
to  Episcopal  Hospital. 

Clinical  Medicine.    Frederick  P.  Henry,  m.d..  Physician  to  Episcopal  Hospital. 

G3rn8ecolog'y  and  Obstetrics.  Benj.  F.  Baer,  m.d.,  late  Instructor  in  Gynaecol- 
ogy, University  of  Pennsylvania ;  Obstetrician  to  Maternity  Hospital. 

Diseases  of  "Women  and  Children.  Washington  H.  Baker,  m.d.,  Obstet- 
rician to  Maternity  Hospital. 

A  SPECIAL    OFFER.  '^°  each  new  subscriber,  who  remits  one  dollar,  in 

— ^M^  advance,  we  will  send  The  Polyclinic  for  one 

year  and  a  copy  of  the  following  book  :  Urinary  and  Renal  Derangements 
and  Calculous  Disorders,  -with  Hints  on  Diagnosis  and  Treatment.  By 
Lionel  S.  Beale,  m.d.,  f.r.s.,  f.r.c.p.,  Professor  of  the  Principles  and  Practice  of 
Medicine  in  King's  College,  London  ;  Physician  to  King's  College  Hospital.  i2mo. 
356  pages.     1885.     Bound  in  strong  paper  covers. 

The  Journal  of  Laryngology  and  Rhinology. 

An  Analytical  Record  of  Current  Literature  Relating  to  the  Throat  and  Nose.    Edited  by  MORELL 
MACKENZIE,  M.D.,  Lond.,  and  R.  NORRIS  WOLFENDEN,  M.D.,  Cantab. 

With  the  Co-operation  of  Dr.  Fauvel  (Paris),  Dr.  Joal  (Paris),  Prof.  Massei 
(Naples),  Prof.  Guye  (Amsterdam),  Dr.  Capart  (Brussels),  Dr.  Hunter  Mackenzie 
(Edinburgh),  Dr.  Michael  (Hamburg),  Dr.  Ramon  de  la  Sota  y  Lastra  (Seville), 
Dr.  John  N.  Mackenzie  (Baltimore),  Dr.  Holger  Mygind  (Copenhagen),  Dr. 
Smyly  (DubUn),  and  Dr.  Greville  Macdonald  (London). 

PUBLISHED    MONTHLY.     PER  ANNUM,  $3.00.  SAMPLE  NUMBERS,  25c. 

THE    OPHTHALMIC    REVI EW. 

A  Monthly  Record  of  Ophthalmic  Science. 

Edited  by  JAMES  ANDERSON,  M.D. ,  London  ;  KARL  GROSSMANN,  Liverpool;  PRIESTLEY 
SMITH,  Birmingham,  and  JOHN  B.  STORY,  M.D.,  Dublin. 

MONTHLY.      SUBSCRIPTION  PER  ANNUM,  $3.00. 

The  Ophthalmic  Review  is  the  only  Journal  devoted  to  this  special  branch  of 
medicine  that  is  published  in  Great  Britain,  and  therefore  represents  the  advances 
made  in  that  country  as  no  other  periodical  can.     Sample  fiutnbers,  25  cents. 


?  QUIZ-COMPENDS  ? 

A  NEW  SEKIES  OF  PKACTICAL  MANUALS  FOR  THE    PHYSICIAN  AND   STUDENT. 

Compiled  in  accordance  with  the  latest  teachings  of  protniftent  lecturers 
and  the  most  popular  Text-books. 

They  form  a  most  complete,  practical  and  exhaustive  set  of  manuals,  containing  information 
nowhere  else  collected  in  such  a  condensed,  practical  shape.  Thoroughly  up  to  the  times  in 
every  respect,  containing  many  new  prescriptions  and  formulae,  and  over  two  hundred  and  thirty 
illustrations,  many  of  which  have  been  drawn  and  engraved  specially  for  this  series.  The 
authors  have  had  large  experience  as  quiz-masters  and  attaches  of  colleges,  with  exceptional 
opportunities  for  noting  the  most  recent  advances  and  methods.  The  arrangement  of  the  sub- 
jects, illustrations,  types,  etc.,  are  all  of  the  most  approved  form,  and  the  size  of  the  books  is 
such  that  they  may  be  easily  carried  in  the  pocket.  They  are  constantly  being  revised,  so  as  to 
include  the  latest  and  best  teachings,  and  can  be  used  by  students  of  any  college  of  medicine, 
dentistry  or  pharmacy. 

Bound  in  Cloth,  each  $i.oo.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 

No.  I.  Human  Anatomy.  Fourth  Edition,  including  Visceral  Anatomy,  formerly 
published  separately.  Over  100  Illustrations.  By  Samuel  O.  L.  Potter,  m.a.,  m.d., 
late  A.  A.  Surgeon  U.  S.  Army.    Professor  of  Practice,  Cooper  Med.  College,  San  Francisco. 

Nos.  2  and  3.  Practice  of  Medicine.  Second  Edition.  By  Daniel  E.  Hughes,  m.d.. 
Demonstrator  of  Clinical  Medicine  in  Jefferson  Med.  College,  Phila.     In  two  parts. 

Part  I. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases  of  the  Stomach,  Intestines,  Peritoneum, 
Biliary  Passages,  Liver,  Kidneys,  etc.  (including  Tests  for  Urine),  General  Diseases,  etc. 

Part  II. — Diseases  of  the  Respiratory  System  (including  Physical  Diagnosis),  Circulatory  System  and  Ner- 
vous System  ;  Diseases  of  the  Blood,  etc. 

*:):*  These  little  books  can  be  regarded  as  a  full  set  of  notes  upon  the  Practice  of  Medicine,  containing  the 
Synonyms,  Definitions,  Causes,  Symptoms.  Prognosis,  Diagnosis,  Treatment,  etc.,  of  each  disease,  and  including 
a  number  of  prescriptions  hitherto  unpublished. 

No.  4.  Physiology,  including  Embryology.  Third  Edition.  By  Albert  P.  Brubaker, 
M.D.,  Prof,  of  Physiology,  Penn'a  College  of  Dental  Surgery  ;  Demonstrator  of  Physiology 
in  Jefferson  Med.  College,  Phila.     Revised,  Enlarged  and  Illustrated. 

No.  5.  Obstetrics.  Illustrated.  Third  Edition.  For  Physicians  and  Students.  By 
Henry  G.  Landis,  m.d..  Prof,  of  Obstetrics  and  Diseases  of  Woinen,  in  Starling  Medical 
College,  Columbus.     Revised  Edition.     New  Illustrations. 

No.  6.  Materia  Medica,  Therapeutics  and  Prescription  Writing.  Fourth  Revised 
Edition.  With  especial  Reference  to  the  Physiological  Action  of  Drugs,  and  a  complete 
article  on  Prescription  Writing.  Based  on  the  Last  Revision  (Sixth)  of  the  U.  S.  Pharma- 
copceia,  and  including  many  unofificinal  remedies.  By  Samuel  O.  L.  Potter,  m.a.,  m.d., 
late  A.  A.  Surg.  U.  S.  Army ;  Prof,  of  Practice,  Cooper  Med.  College,  San  Francisco.  4th 
Edition,  with  Index. 

No.  7.  Inorganic  Chemistry.  New  Edition.  By  G.  Mason  Ward,  m.d..  Demonstrator 
of  Chemistry  in  Jefferson  Med.  College,  Phila.  Including  Table  of  Elements  and  various 
Analytical  Tables.     New  Edition. 

No.  8.  Diseases  of  the  Eye  and  Refraction,  including  Treatment  and  Surgery.  By  L. 
Webster  Fox,  m.d.,  Chief  Clinical  Assistant  Ophthalmological  Dept.,  Jefferson  Medical 
College,  etc.,  and  Geo.  M.  Gould,  a.b.     40  Illustrations. 

No.  9.  Surgery.  Illustrated.  Third  Edition.  Including  Fractures,  Wounds,  Disloca- 
tions, Sprains,  Amputations  and  other  operations;  Inflammation,  Suppuration,  Ulcers, 
Syphilis,  Tumors,  Shock,  etc.  Diseases  of  the  Spine,  Ear,  Bladder,  Testicles,  Anus,  and 
other  Surgical  Diseases.  By  Orville  Horwitz,  a.m.,  m.d..  Demonstrator  of  Anatomy, 
Jefferson  Medical  College.  Third  Edition.  Revised  and  Enlarged.  77  Formulae  and  91 
Illustrations.    • 

No.  10.  Organic  Chemistry.  Including  Medical  Chemistry,  Urine  Analysis,  and  the  Analy- 
sis of  Water  and  Food,  etc.  By  Henry  Leffmann,  m.d.,  Demonstrator  of  Chemistry  in 
Jefferson  Med.  College ;  Prof,  of  Chemistry  in  Penn'a  College  of  Dental  Surgery,  Phila. 

No.  II.  Pharmacy.  Based  upon  "  Remington's  Text-Book  of  Pharmacy."  By  F.  E. 
Stewart,  m.d.,  ph.g.,  Quiz-Master  at  Philadelphia  College  of  Pharmacy.     Second  Ed. 

Bound  in  Cloth,  each  $1.00.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 

Jl^^  These  books  are  constantly  revised  to  keep  up  with  the  latest  teachings  and  discoveries. 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  Street,  Philadelphia. 


NOW  READY. 

With  Many  Improvements  for  1888. 

37th  YEAR. 
The  Physician's  Visiting  List. 

(LINDSAY  &  BLAKISTON'S.) 

CONTENTS. 

Almanac  FOR  1888  and  1889.  I    Posological  Table,  Meadows. 

Table  of  Signs  to  be  used  in  keeping  accounts.  '    Disinfectants  and  Disinfecting. 

Marshall  Hall's  Ready  Method  in  Asphyxia.  „  ^,  ,        ,     , 

Poisons  and  A.ntidotes  Examination  of  urine.  Dr.  J.  Daland,  »(jj^rf«/<?« 

The    Metric    or    French     Decimal    System    of    I        7>Wj  "  Practical   Examination   of  Urine."      5th 


AVeights  and  Measures, 
Dose  Table,  revised  and  rewritten  for  1888,  trj'  Ho 

BART  Amory  H.^re,  m.  d.,  Demonstrator  of  Thera 

peutics,  University  of  Pennsylvania. 
List  of  New  Remedies  for  1888,  by  same  author. 
Aids  to  Diagnosis  and  Treatment  of  Diseases  of 


Edition. 

Incompatibility,  Prof.  S.  O.  L.  Potter. 
A  New   Complete  Table  for  Calculating  the 

Period  of  Utero-Gestation. 
Sylvester's  Method  for  Artificial  Respiration. 
D1AGR.A.M  OF  the  Chest. 


the  Eye.  Dr.  L.  Webster  Fox,  Clinical  Asst.  Eye  ^lank    Leaves,    suitably   ruled,  for   Visiting    List 

Dept.  Jefferson   Medical  College  Hospital,  and   G.  Monthly  Memoranda;    Addresses  of   Patients  and 

M  Gould                                         a            r       >  others;  Addresses  of  Is  urses,  their  references,  etc. ; 

Diagram  S  ho^hng  Eruption  of  Milk  Teeth,  Dr.  Accounts  asked  for  ;  Memoranda  ofWants  ;  Obstet- 

Louis  Starr,  Prof  of  Diseases  of  Children,  Univer-  1       "=  jind  \  accmation  Engagements ;  Record  of  Births 

sity  Hospital,  Philadelphia.  ^^  Deaths  ;  Cash  Account,  etc. 

A  NUMBER  OF  IMPROVEMENTS  and  additions  have  been  made  to  the 

reading  matter  in  the  first  part.  This  has  been  done,  however,  without  increasing 
the  number  of  pages.  Great  care  has  been  taken  in  selecting  the  leather  for  the 
covers  and  in  each  detail  of  manufacture. 

SIZES  AND  PRICES. 


For  25 

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weekly. 

Tucks, 

pockets  and  Pencil,  $1.00 

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2  Vols      {Jan.  to  June  1 
2  vols.     1  July  to  Dec.  J 

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INTERLEAVED   EDITION, 

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Interleaved,  tucks  and  Pencil,    1.25 

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PERPETUAL  EDITION,  without  Dates. 

B@°*C(a:«  5e  commenced  at  ajiy  time,  and  used  until  full.     Similar  in  style,  con- 
tents and  arrangement  to  the  regular  edition. 
No.  1.     Containing  space  for  over  1300  names,  with  blank  page  opposite  each 

Visiting  List  page.  Bound  in  Red  Leather  cover,  with  Pocket  and  Pencil,  $1.25 
No.  2.    Containing  space  for  2600  names,   with  blank  page  opposite  each 

Visiting  List  page.     Bound  like  No.  i,  with  Pocket  and  Pencil,  .     .      .      .      1.50 

These  lists,  without  dates,  are  particularly  useful  to  young  physicians  unable  to 
estimate  the  number  of  patients  they  may  have  during  the  first  years  of  Practice,  and 
to  physicians  in  localities  where  epidemics  occur  frequently. 

"  For  completeness,  compactness,  and  simplicity  of  arrangement  it  is  excelled  \,y  none  in  the  market." — N.  Y. 
Medical  Record. 

"  The  book  is  convenient  in  form,  not  too  bulky,  and  in  every  respect  the  very  best  Visiting  List  published.   — 
Canada  Medical  and  Surgical  Journal. 

"After  all  the  trials  made,  there  are  none  superior  to  it." — Gaillard's  Medical  Journal. 

'.'<  D        ,  ^^'^°™-^  Standard. "Southern  Clinic. 

'^  Regular  as  the  seasons  comes  this  old  favorite." — Michigan  Medical  Ne^us. 
It  is  quite  convenient  for  the  pocket,  and  possesses  every  desirable  qualit>^" — Medical  Herald. 

'^  The  most  popular  Visiting  List  extant." — Buffalo  Medical  and  Surgical  Journal.  ^  rj-    • 

"We  have  used  it  for  years,  and  do  not  hesitate  to  pronounce  it  equal,  if  not  superior,  to  any." — Southern  CltntC.^ 

"  This  Visiting  List  is  too  well  known  to  require  either  description  or  commendation  from  us." — Cincinnatt 
Medical  News. 

P.  BLAKISTON,  SON  &  CO.,  Publishers,  1012  Walnut  Street,  Philadelphia. 
S^"  Large  Stock  of   Physicians    Ledgers  of  Various  Kinds. -@a 


DATE  DUE 

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in  USA 

